DR. MANI MENON

Robotic-assisted radical prostatectomy (RAP) is the dominant minimally invasive surgical treatment for patients with localized prostate cancer. Only a few large series have been published to date, with few long-term data available. The current study presents what to the authors' knowledge is the largest series of patients undergoing RAP with the longest follow-up to data available to date. Using a continuous quality improvement initiative, several technical refinements were adopted, evaluating the impact of this on patient outcome.

Minimally invesive surgery is gentler to the patient then conventional surgery. The robotics surgical techniques that we have developed harness the powers of computers to the skill

The mean age of the patients was 60.2 years and the mean prostate-specific antigen (PSA) level at time of diagnosis was 6.43 ng/mL; 42.4% and 64.2% of patients, respectively, had a biopsy and pathologic Gleason sum of . The mean surgical and console time was 154 minutes and 116 minutes, respectively. Estimated blood loss was 100 mL; 96.7% of patients were discharged within 24 hours of surgery. At a median follow-up of 22 months, 7.3% of men had a PSA recurrence. The 5-year actuarial biochemical free survival rate was 84%.

To the authors' knowledge, the current study is the first report of 5-year outcomes in men undergoing RAP. These data demonstrate that RAP can be performed with favorable outcomes while minimizing complications. As experience increases, further improvements in clinicopathologic and functional parameters are achieved.

Cancer 2007;110:1951-8.© 2007 American Cancer Society.

Developed by surgeons at Henry Ford Hospital's Vattikuti Urology Institute, a new technique of nerve-sparing robotic prostatectomy called the Veil of Aphrodite results in significantly better erectile function outcomes than in those who receive conventional nerve-sparing surgery - without compromising cancer control.

Learn more about the study.

From the Vattikuti Urology Institute, Henry Ford Health System, Detroit, Michigan

Contemporary techniques of radical prostatectomy achieve excellent oncological 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 oncological outcomes achieved by the radical retropubic prostatectomy. We present our current technique of VIP with preservation of the lateral prostatic fascia (“veil of Aphrodite”).

To date, 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. Oncological and functional outcomes were obtained through a questionnaire collected by a third party not involved in patient care.

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

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

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To report updated results, at 1 year of follow-up, of a modified nerve-sparing robotic radical prostatectomy that preserves the lateral prostatic fascia (Veil of Aphrodite).

From January to December 2003, 154 consecutive men had a Vattikuti Institute prostatectomy with Veil of Aphrodite nerve-sparing by one surgeon. A prospective database recorded patient demographics, intraoperative, peri-operative, and pathological variables. Peri-operative complications were recorded using the Clavien classification. Patients had serum prostate-specific antigen (PSA) levels measured every 3 months and self-administered the International Prostate Symptom Score and Sexual Health Inventory for Male questionnaires before and at 1 year after surgery.

The men had a mean age of 57.4 years, a mean body mass index of 27.2 kg/m(2), and a mean PSA level before surgery of 5.11 ng/mL. The mean operative duration was 122 min. At 1 year, 96% of the men reported having had intercourse and 71% had recovered normal erectile function. One man had a Clavien grade II complication, 4.6% of men with organ-confined disease had positive surgical margins, and no patient had a PSA recurrence at 12 months; 97% of the men were continent at 1 year, and the median time to continence was 14 days.

Veil of Aphrodite nerve-sparing surgery provides better recovery of sexual function at one year than in contemporary series from centres of excellence, without compromising cancer control and urinary function.

To describe a feasibility study of our ability to preserve the prostatic fascia in men undergoing robotic radical prostatectomy. The prostate is covered anterolaterally by prostatic fascia, also called lateral pelvic fascia or the parietal layer of endopelvic fascia. The prostatic fascia is rich in vessels, nerves, and smooth muscle. We hypothesized that preservation of this fascial layer may result in improved postoperative potency.

The technique was first attempted in 15 men undergoing radical cystoprostatectomy, in which accidental entry to the prostatic tissue is not critical. Thereafter, it was performed in 6 impotent men undergoing robotic radical prostatectomy. The fascia was excised and stained for prostate-specific antigen and neural and muscle tissue. The technique was then performed in 35 potent men (Sexual Health Inventory for Men score greater than 21) undergoing robotic radical prostatectomy. Postoperative potency was evaluated with a self-administered questionnaire (Sexual Health Inventory for Men).

Under the magnification of the da Vinci robotic system, and also shown histologically, the prostatic fascia is a multifascial layer of fibrovascular tissue, covering the anterolateral aspect of the prostate. It stains positive for smooth muscle and nerves, but negative for prostate-specific antigen. The amount of neural tissue in the fascia is variable, but never exceeds that in the neurovascular bundle. At 12 months of follow-up, 34 (97%) of 35 men undergoing fascia-preserving robotic radical prostatectomy had erections strong enough for vaginal penetration, and 30 (86%) had normal erections (Sexual Health Inventory for Men greater than 21).

Preservation of the prostatic fascia is safe and feasible, without compromising the surgical margins, and allows enhanced preservation of neural tissue during robotic prostatectomy with an apparent improvement in potency.