DR. GOMELLA: If I want to come to the center and have my prostatectomy done you and your team, how much will it cost me?

DR. MENON: It is hard to say. If you were an international patient, and you were paying cash, it would cost you $20,000 to have an open prostatectomy, and $30,000 to have a VIP.

DR. GOMELLA: That's total package cost to the hospital, surgeon's fees and everything?

DR. MENON: Right, everything included.

We do have an occasional patient, once a year we get somebody from Canada who wants to do that. But other than that, we have people we take insurance from, and people we don't. And so most people -- their insurance companies pay what they would pay for a conventional procedure or less. Blue Cross pays less than if you were to have an open prostatectomy, because they say if you have a 7 centimeter incision, it is a regular prostatectomy. If you have a 3 centimeter incision, it is not a prostatectomy.

DR. GOMELLA: That's right, the hole is smaller, so it can't be as hard.

PARTICIPANT: Tell us about the veil of Aphrodite.

DR. MENON: Oh, the veil of Aphrodite. I have to show it to you. Essentially, we have talked about the cavernosal nerves as being posterior. But every slide that looks at prostates shows nerve bundles on the lateral surface on the prostate -- on the anterior surface of the prostate.

These have been shown in experimental studies and otherwise to be cavernosal nerves. In the rat, for instance, they account for 50 percent of erectile function. Every study that has looked at radical prostatectomy has shown that the quality of erection after radical prostatectomy is lower than the quality of erection before radical prostatectomy, when that question has been asked.

We have been very careful in not asking that question, but when it has been asked, it has been shown that's the case.

So robotic assistance allows you to go between the lateral pelvic fascia, prostatic fascia, and the capsule of the prostate and preserve the nerves. And so we have done this in about a dozen patients. It's a pain in the neck to do it, because you are dissecting underneath Baxon's plexus. That's the veil of Aphrodite.

DR. STRUP: A couple of quick questions. I also enjoyed the robotic presentation. But I had a couple of questions in terms of stay. Do they go home, home, as in like back to Grand Rapids and Dearborn? Or do they have a hotel facility that is on campus?

DR. MENON: No, they would go home if their home is in the Detroit metropolitan area. If it's Grand Rapids, we would keep them overnight, or the residents' quarters has a suite that they can use. But they could go home to Grand Rapids if they wanted to. That's why I said 98 percent of eligible patients. I wouldn't want to send somebody to Grand Rapids home.

DR. STRUP: And then in terms of the device, I know they have ultrasound and so forth with the Da Vinci model now. But it seems like it's an awful lot of cauterizing. We have really tried to get away from that. The early results look impressive, but I see a lot of cautery action. How much have you really gotten away from that?

DR. MENON: The cauterizing that you see, I pretty much use the same amount now. So the results are with the bad technique that you saw.

DR. RAMIN: Hi, my name is Saroosh (?) Ramin from City of Hope. We have done a number of laparoscopic prostatectomies also. We used the AESOP machine and the DaVinci. Do you think the DaVinci would be easier to teach others on how to do laparoscopic prostatectomies?

DR. MENG: We have done both pure laparoscopy and robotic prostatectomy, but I think a lot of the times we have done a lot of pyeloplasties and other reconstructive procedures. So I think the transition was not as difficult. I think the robotic, with that extra degree of freedom, makes sewing the anastomosis much easier. So I think there is a difference between the two.

DR. MENON: If you are a very, very good laparoscopic surgeon, I think the AESOP would be better. So for your group, which has the biggest traditional laparoscopic series in this country, the Da Vinci I think would offer very little. It would actually slow you down. You would have a learning curve for the Da Vinci, where you have to unlearn all the movements that you have done with the laparoscopic procedure.

The Da Vinci the movements are like this. The laparoscopy, it's like this. So for the very accomplished laparoscopic surgeon, you are talking about a few steps backwards before you get back. If you are not so skilled a laparoscopic surgeon, the Da Vinci is much more intuitive. It's closer to what you have done open.

DR. RAMIN: There is one other comment I just wanted to make. I definitely agree with you that whoever is going to be doing laparoscopic cancer surgery should really be an open surgeon, and should be trained in oncology surgery. In other words, the people who will know the anatomy of a good prostatectomy are the people who have had some experience doing open surgery. And they are the ones that I think are going to get the negative margins, and the good continence rates, and also cure the patients.

That also applies I think to nephrectomies.
I had one other question for you. When you opened the prostatic fascia and get into the space between the capsule and the fascia, how high on the prostate are you opening? How anterior are you?

DR. MENON: Starting say about two o'clock to ten o'clock. So we just leave the traction stitch, and then go as close to the traction stitch. I place a traction stitch a little differently, deeper, rather than wide, and then open it.

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