SLIDES & TRANSCRIPTS
Saturday, December 14, 2002

Lap Prostatectomy: An Evolving Art

Mani Menon, M.D.

So this talk is just going to talk about what we are doing, the VIP procedure. And I will tell you when to put your glasses on.

This is a six port approach that Ashutosh Tewari has developed. It takes about 15 minutes to dock the robot. The nurse who is moving the robot is a nurse from Singapore, who is visiting us. Singapore has bought a robot, and they are setting this up.

There is a camera port, two metallic Da Vinci ports, and then there are three regular laparoscopic ports.

Our team is very, very good at setting up the robot. It takes them about 15 minutes. My job is very easy. I sit down and play at the console.

We start the dissection anteriorally, taking down the peritoneum in between the medial umbilical ligaments. Here I am taking down the vas. So this is different from the Montsouris approach.

Now, the peritoneum has been taken down here. We are identifying the pubic synthesis. And we are doing a node dissection. This is the nodal packet being take out. That's the node of Cloque.

We do a node dissection in people with the Gleason 6, if it's over 50 percent, and everybody with Gleason 7, 8, 9, and 10. It turns out that we perform a node dissection in about 41 percent of our patients.

We open up the interpelvic facia now. Occasionally, we try to preserve the anterior or the accessory cavernosal nerves, and then we don't do it quite this way, but for most of the patients, this is what we do.

Controlling the dorsal vein. There is the apex of the prostate. There is urethra with the dorsal vein complex in front of it. You could do this dissection fairly extensively, but we use a minimalistic approach, because we want to maintain the sphincter intact as much as possible.

So this is the CT1 needle, 6 inch suture, 0 micro. I'm not doing this, Ashutosh Tewari is doing it. I usually pass the needle from the left to the right. This is how I know that he is doing it. And then we pass it just behind the pubo-prostatic or the pubo-urethral ligaments and tie it down.

Again, this is Ash Tewari doing this part of the operation.

We place a traction suture in the prostate. This is me doing that portion. I don't really see any difference in the knot tying ability of Ash versus me. I tie with my right hand, and he ties with his left.

We then try to release the neurovascular bundle at the apex. This is where the nerves are closest to the prostate. We don't use any cautery here. We use either the needle holder or the hook, but without putting current on it.

You can see at twelve o'clock the levator ani muscle that Bob Myers has described so brilliantly.

Releasing this helps detach the apex at the end of the procedure much better.
The anterior bladder neck is identified at the convexity of the prostate, and where you can see the detrusor. We use the 30 degree lens looking down. And it literally takes 3 minutes to incise the anterior bladder neck. Usually, I start laterally, because there is more tissue there between the bladder and the prostate. You don't have to worry so much, it's in the midline where it is attached.

The catheter is lifted up to the ceiling, and the posterior bladder neck is incised.
Once you incise the posterior bladder neck, you will come across the anterior layer of Denonvillier's fascia . You can kind of see it at the bottom there. Because this is an edited and abbreviate movie, you are not seeing it that well.

The assistant now grabs the anterior layer of Denonvillier's fascia, take the catheter out. And now you can see the vasa. And this again, is a big difference from this approach to Vallancien's approach where this portion of the dissection is done first. And we have a reason for doing it this way. The primary reason is that it's closer to what I have done open than the French approach.

The vasa are transected, and then the seminal vesicals are identified. Again, I think this Ash Tewari doing this portion of the case. I usually control the vesical pedicle before doing this part of the dissection.

In a young person we may leave the tips of the seminal vesicals behind. Marty Sanda has a nice paper indicating that this might improve the quality of erections post-operatively. We don't have data to support this, but this is what we have been doing.
And we open up the posterior layer of Denonvillier's fascia. In somebody whom preservation of potency was a goal, we would not use the hook, but would use the bipolar forceps and the scissors. At the time this movie was made, which is early on in our series, the bipolar was not available, and so that's why we used this.

And here is the pedicle control. Generally, I like doing this before dissecting the seminal vesicals, which is why I think this is not me doing the operation, but Dr. Tewari.

Incising the lateral pelvic or the prostatic facia. And posterially you can see the neurovascular bundle separating out rather nicely. You do get into some venus sinuses. You can see one open sinus. But the bleeding is held under control, because of the pneumoperitoneum. And once the specimen is out, the veins retract, and there is usually not much bleeding.

And again, we use very gentle traction, stay as anteriorally as possible. And this transection of the lateral pelvic fascia is on the lateral surface of the prostate.
There are a few attachments between the rectum and the prostate that need to be taken down.

Urethra transection. This is an early version. I don't do it quite like this. This is more like the French team, with a sound in the urethra. We now just use a catheter and come across.

And the prostate is out. We then do apical biopsies. And this is controversial. I like doing it. Particularly, I think you heard what Ed Messing said, that 50 percent of the time there are some BPH glands left behind even in Herb Lepor's hands. So by doing this, and saving the urethra, we essentially keep cutting tissue until there is no more BHP left behind.

The next is the anastomosis. I don't use this stitch anymore. I use a different stitch, but this is a running anastomosis in this instance. I use a stitch called the MVAC stitch, which allows me not to put a posterior knot, and we can talk about that later, after the session perhaps. And the anastomosis will be done, and I'm going up to finish up.

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So here is the evolution. It started in 1999, with the planning of the program. At that point there had been no publication about laparoscopic radical prostatectomy, or perhaps just one paper in the prostate.

We got an AESOP robot in 2000. Guillonneau and Vallancien came and mentored us, and they actually did 50 cases with us. And then we started using the DaVinci in November 2000.

We actually purchased the Da Vinci and had it installed in March 2001. We have done over 350 robotic cases now with the VIP technique that I showed, which we started doing in September 2001.

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Now, why did we move to robotics? And this for Dr. Grayhack, if he is still here, or for him even if he isn't here. Danny Ozark, who was the manager of the Chicago Cubs, was once asked after a road trip were the Cubs won four games and lost four games as to what his thoughts were, and he said, it could have easily gone the other way.

So we could have been stuck with robotics, but we thought if we had to rationalize this, that robotic surgery combines the skills of open and laparoscopic surgery, it truly does. For me at least, it was a lot easier to master than traditional laparoscopic surgery, even though we had the best collaboration we possibly could have gotten.

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The steps in the evolution were again, we got the Da Vinci in 2000. Each one of the steps here, and I won't bore you with this, was a change made, planned, analyzed, and then we went on. So since my talk was really the evolution of the thing, I felt ought to show where we changed, and how we changed.

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And we were only able to do this because we had a team. We would analyze the data before and after. And here we have made 11 changes so far,

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15 changes from the traditional Montsouris approach. The last two are still in process. The veil of Aphrodite is preservation of accessory cavernosal nerves. And most of our patients now are discharged within four hours of surgery. So by the time the second patient is done, the first patient goes home. And by the time the third patient is done, the second patient goes home.

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The surgeon who doesn't have complications should stopped operating. And I have had complications. This is not my own, these are some of Jim Peabody, my associate, whose complications are included. We had 8 complications in our first 100 VIPs, and 2 in our second 100 VIPs, for a total of 5 percent.

A lot of the complications stemmed from the fact that initially, we were not skilled laparoscopic surgeons. We had not done a single laparoscopic case at Henry Ford Hospital before we started doing laparoscopic radical prostatectomy.

The ileus, by and large, was because we were very worried that they were having hernias. And if they came in with constipation, we admitted them. Three of the four ileuses resolved within 24 hours with just constipation. One patient did have a 15-day ileus.

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My own personal series, and I'm comparing my first 50 to the last 50, is that my operative time has come down from 195 minutes to 140 minutes. Operative time is defined from the time the needle is put in for the pneumoperitoneum to the time the bandage is applied. If you looked at the actual time I am operating, it's about 15 minutes less than, 15-20 minutes less than that.

The blood loss has gone down. It is less than 100 ccs. Often times it is difficult to quantitate it, because it is so little.

The hospital stay, recently 98 percent of the eligible patients have gone home the same day. So it's far less than one day. The catheter is in for four days. And our positive margin rates after we started doing the parietal biopsies have dropped from 12 percent to 6 percent. Four of the positive margins are focal, and two were extensive.

This is not bad, looking at the baseline of disease that we do. Sixty percent of our patients had Gleason 7 and above, and the volume of tumor is 5-7 ccs.

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How does one know whether an operation is good? How do you define a good operation versus a bad operation, and how do we compare it? You have seen Dr. Gomella's slide saying we need to compare it to open surgery to see that it's any better.

And of course I could simply say it's better, and that would be my preference. But really, the patients are the ones who answer the question. So we asked patients over a one month period, and this is an unscientific approach -- I gave them a questionnaire when they were signing up for the VIP saying, why do you want to have this VIP done? What is it that you hope to achieve from this?

And by and large, the most important thing for them pre-operatively -- that changes after surgery -- was they wanted removal of cancer as much as possible. Secondly, the rated continence, and the duration of incontinence is important to them. They knew that they would become continent in a year, but they would much rather be continent in a month, rather than a year.

Potency was important. Safety, they would like a safer operation, the safest they could. Easier recuperation, and finally, if we didn't have to transfuse, they would like that.

Note that operative time or date of stay, which is very important to us and to the administrators, were not at all important for the patients. They didn't really care if the operation took an hour longer or an hour shorter. Of course if the operation took a day longer, that would be different.

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So based on this, we did an analysis of how patients did. In terms of negative margins, we did 100 open radical prostatectomies during the same period as these VIPs. Of the last 100 that we did, 76 percent of them had negative margins, which mean 24 percent had positive margins. Most of these were focal, but nonetheless, this was our own series. With the VIP and my own personal series, a positive margin rate of 6 percent.

At 6 months, 60 percent of our open patients were wearing no pads. At 6 months a third of them were having sexual intercourse. We had a 15 percent complication rate for our open cases. And the pain score was 7 out of 10. There is asterisk in here, and I'll explain that if somebody wants to later.

Eighty-seven percent of our patients required some blood product or the other, but only 11 percent of them had a bank blood transfused. The rest of them had either cell saver or autologous blood.

So in theory, if you had an operation that had 100 percent negative margins, 100 percent of patients were continent in 6 months, 100 percent of them were potent, and so on and so forth, you would achieve a score of 600. And our score was 373 for the open radical prostatectomies that we did at Henry Ford Hospital, which said that we were about 62 percent. If this was an SAT score, this would be 62 percent of this.

And with the VIP that we do, using these numbers, our score is 524, which means we are at 87 percent. This then perhaps is the window of opportunity that we have to go from 524 to 600.

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How did we evolve from laparoscopic prostatectomy to robotics? In 2001, we had done 50 cases. The operative time -- now, here we are using a different definition. This is the definition that we used in the paper that we published in the Journal of Urology -- was 258 minutes, start of dissection to closure. These were not my cases, they were done by Betrand Guillonneau or Guy Vallancien, assisted or maybe hampered by Jim or me. The blood loss was 390 ccs, 1-2 cases a day, 65 percent were discharged within 24 hours.

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As of now, we have done 426 laparoscopic prostatectomies, 375 with the robot, 343 with the technique we have used. The operative time, taking out the time for setting up the robot, and making a fair comparison, dissection to closure is 120 minutes, slightly lower if we don't do the nodes. The blood loss is around 75 ccs. We do three cases a day, and 94 percent of the patients we want to send home are discharged within 4-6 hours of surgery.

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This has had a pronounced impact on the patient volumes. Patients drive this. It's not the doctors that are sending the patients. It's the patients who are finding out and coming here. In 2000, we did 176 radical prostatectomies in our group. We just had the French team come for three months of this, and they had done 17 cases.
The first year, there was a 25 percent increase in volume, but a huge shift from open surgery to robotics. We hadn't done a single robotic case in 2000. In 2002, annualized, we will do 350 cases.

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Our goals are 90 percent potency at 6 weeks. I doubt that we will succeed. It will require modification of techniques, as well medical therapy. Ninety percent continence on catheter removal. I think we can do that even now, if I was more diligent about preserving the bladder neck. I don't do that, but that could easily be done technically.

And I would like to get the OR time down to 90 minutes. And if that was a primary goal, and I wasn't teaching, I think we could do that.

But the real goal, the one that I really, really want to do is to convince Pat Walsh to do a VIP.

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