Vattikuti Institute prostatectomy, a technique of robotic radical prostatectomy for management of localized carcinoma of the prostate: experience of over 1100 cases
Section snippets
Development of robotic radical prostatectomy (RRP)
The authors often are asked what caused us to develop techniques of robotic prostatectomy. Serendipity and a lack of sophisticated laparoscopic skills are the two most probable reasons. The authors began by trying to establish a pure laparoscopic radical prostatectomy program under the guidance of and formal collaboration with Guillonneau and Vallancien of Montsouris, but rapidly learned that Menon (at least) was untrainable. Because the authors were reasonably comfortable with the Walsh-Lepor
Technique of Vattikuti Institute prostatectomy (VIP)
The authors began performing LRP in October 2000 and robotic radical prostatectomy in March 2001, and have done over 1100 robotic radical prostatectomies. Initially, the authors performed robotic radical prostatectomy by duplicating the steps of the Montsouris approach of LRP, but soon modified the technique to reflect the experience gained from “open” surgery, incorporating many of the steps of conventional radical retropubic prostatectomy. The authors' current approach—Vattikuti Institute
Development of extraperitoneal robotic prostatectomy technique
The VIP is a hybrid technique that uses large peritoneal space for pneumo-insufflation, placement of the ports, and suction of smoke during the procedure. Except for the initial step of dropping the bladder, the rest of the procedure is performed in extraperitoneal space. The procedure also can be done with a completely extraperitoneal approach. The two approaches are similar, with the exception of port placement and creation of the working space.
Postoperative care
Patients generally are discharged from the hospital within 24 hours. They return to the office 4 to 7 days after surgery for a cystogram and catheter removal. If there is no extravasation, the Foley catheter is removed. If extravasation is noted, then the catheter remains in place an additional 7 days and is removed without additional imaging.
Results
The authors have performed over 1100 cases of robotic radical prostatectomy. The operating time (Veress needle to closure) ranged from 70 to 160 minutes and the blood loss ranged from 50 to 250 mL. Approximately 20 to 40 minutes was spent in placing the ports, lysing any adhesions, retrieving the specimen, and closing the port sites. Thus, the actual robotic dissection (console) time is approximately 90 to 100 minutes. Pelvic lymphadenectomy took 18 minutes on average. No patient has required
Comparison of conventional, laparoscopic, and robotic radical prostatectomy at the authors' center
The authors also examined the outcomes of robotic radical prostatectomy and compared them to those of open and conventional LRP. The authors prospectively collected baseline demographic data on all patients undergoing surgery for prostate cancer over a 4-year period at their center. Urinary and sexual function were evaluated using standardized criteria preoperatively, and at 1, 3, 6, 12, and 18 months after the procedure. In addition, patients answered a mailed-in, validated questionnaire at
Complications
There was no operative mortality and no patient was converted to open surgery. No patient received an intraoperative transfusion. There were 21 unscheduled postoperative visits for transient urinary retention after early catheter removal (15), dysuria (four) or hematuria (two). Postoperative complications were defined according to the classification of Clavien. Grade-1 postoperative complications were defined as deviations from ideal occurring within 30 days of surgery. There were 10 Grade-1
Functional results
Total continence, defined as using no pad, was achieved in 96% of patients at a follow-up of 6 months, at a median time of 42 days [13], [23], [24]. Based on validated third-party questionnaires (Expanded Prostate Cancer Index Composite), 82% of preoperatively potent patients younger than 60 years of age had a return of some sexual activity, and 64% had had sexual intercourse at a follow-up of 6 months. Of patients over 60 years of age, 75% had had some sexual activity and 38% had had sexual
Comments
Laparoscopic technique provides four degrees of freedom of movement, compared with robotic surgery, which provides six degrees of freedom. In addition, current laparoscopic displays do not provide three-dimensional orientation and lack tactile feedback. The instruments are not ergonomically suitable for difficult operations such as an LRP [48]. In the earlier experience of LRP, the greatest time required was in creating the urethrovesical anastomosis, which took twice as long as the time for
Summary
Advances in surgical techniques, technology, and surgeons' skills have allowed robot-assisted radical prostatectomy to be an option in the management of organ-confined prostate cancer. The goals of the VIP technique are to cure cancer, preserve urinary continence, preserve potency, and decrease morbidity, along with the benefits of a minimally invasive surgery and excellent cosmesis. VIP is nearly equal to traditional retropubic prostatectomy, with certain outstanding advantages.
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