This is the latest in minimally invasive surgery, offering the most recent advances in robotics and computer technology for a patient with prostate cancer. This system allows us surgeons to be even more precise with ridding cancer from the prostate. There is no computer programming of surgical instructions. We treat each surgery as a unique operation. Even difficult operations become routine with the da Vinci system.
With this operating system, patient recovery is so fast that many return to work in two to three weeks after this state of the art surgery. Our patients are pleasantly surprised to feel little if any sensitivity at the incisions sites and barely notice the scar tissue. As an added benefit, this system completely removes any cancer cells that are at the surrounding edge of the prostate. The elimination of any malignant cells at the surgical margins is critical to patient recovery. Our patients report a return of their sexual drive and their ability to attain an erection during sexual intercourse after prostate surgery. Also, they are glad to regain control of their bladder and report no problems with urination. With all of these positive outcomes in mind, we are happy to offer da Vinci Prostatectomy to our patients as the ultimate form of surgery for prostate cancer. We prefer this method over all others because it has the most important advantages for you, the patient.
We perform this surgery while sitting comfortably at a console in the operating room and viewing the surgery on an enhanced 3D High Definition monitor. Our hands are wrapped around joy sticks, which control our movements which are then translated under real time into the scaled movements of a robotic device that enables the operation to take place. The ends of the robotic arms are fitted with miniature surgical instruments that are capable of moving in any direction. These endo-wrists can be directed with extreme accuracy and precision.
This system allows us to operate for longer periods of time with less fatigue and virtually no hand tremor. The da Vinci Surgical System provides delicate handling of the prostate tissue permitting extremely accurate cutting of nerve tissue. Only 5 small quarter sized incisions are made into the patient’s abdomen, three on one side of the navel and two on the other side. The fine robotic arms equipped with tiny surgical instruments enter through these ports and do the surgery. Keep in mind that we, the surgeons, control every move that the robot makes.
For surgery, we highly recommend the da Vinci Robotic Surgical System. We believe that you will get the greatest clinical outcome with this revolutionary, state-of-the-art surgery. Not only is it minimally invasive, but also allows us to rid cancer cells. Our patients report minimal discomfort after the surgery and are amazed at how quickly they recover and return to all of their normal activities. Traditional open surgery involves large traumatic incisions to the patient and requires a longer healing time with the possibility of infection at the surgical site and considerable scarring. With the da Vinci system, even through the small one-centimeter keyhole incisions, we are able to make incredible surgical maneuvers that would be impossible to make with our hands inside the patient.
Chairman of Urology, Chief of Robotic Surgery at Lenox Hill Hospital Professor of Urology at Hofstra North Shore-LIJ School of Medicine in New York City.
Dr. Samadi is one of the very few urologic surgeons in the United States trained in oncology, open, laparoscopic, and robotic surgery. He is also the first surgeon in the United States to successfully perform a robotic surgery redo. To date, Dr. Samadi has performed over 5,600 prostate surgeries. This is more than any other prostate cancer surgeon in all of New York.
This approach, using tested oncologic open RRP principles, yields favorable continence, potency, and margin rates. The latest in urologic surgical techniques and office-based procedures.
By David B. Samadi, MD • Hugh J. Lavery, MD
Since the original description of the robot-assisted laparoscopic prostatectomy (RALP) technique in 2002 (Urology 2002; 60:569-72), several technical modifications have been reported. These modifications are primarily designed to reduce positive surgical margin rates and improve continence and potency rates. Our group’s current technique at the Lenox Hill Hospital, as described in this article, incorporates several of these advancements.
Our goal in adopting these modifications is to maintain the tested oncologic principles of open radical retropubic prostatectomy (RRP) on a robotic platform, incorporating evidence-based medicine whenever possible. To this end, we will focus on three areas of advancement: the handling of the dorsal vein complex (DVC) and endopelvic fascia (EPF), a “high anterior release” technique of nerve sparing, and bladder neck reconstruction.
We then describe our current technique. Dorsal vein complex In the original RALP technique, the DVC was ligated in a figure-of-eight fashion early in the procedure, following dissection of the prostate from the EPF lateral to the prostate. The suture is placed in a notch located between the DVC and urethra, similar to the technique used in open RRP. However, concerns were raised that this stitch may affect apical margin rates and functional outcomes.
Indeed, this has been a topic of debate since 1998, when Brendler modified his RRP technique to avoid suture ligature of the DVC (J Urol 1998; 159:1281-5), although this modification did not gain widespread popularity due to the significant blood loss associated with it. Urethral or sphincteric muscle fibers may be inadvertently incorporated into the stitch, affecting continence. Similarly, the stitch may catch the yet-to-be-dissected neurovascular bundles and affect potency. The DVC stitch also tends to bulk the tissue anterior to the prostate, distorting its anatomy and making the apical dissection more difficult, potentially increasing the rates of positive apical margins. Several groups have begun advocating cutting the DVC cold, without prior ligation. The DVC is then oversewn following removal of the specimen. Decreased rates of apical positive surgical margins (J Endourol 2009; 23:123-7; Eur Urol 2007; 51:648- 57) and faster recovery of continence (Eur Urol 2009; 55:1377-83) have been demonstrated with this modification.
Opening the EPF/nerve sparing Preservation of the lateral EPF may be associated with higher rates of continence after prostatectomy, due to preservation of levator ani function (Eur Urol 2009; 55:892-900). Traditionally, an incision into the lateral EPF was used to access the DVC for its ligation. However, the omission of the DVC stitch permits the avoidance of this step and any potential damage to the neurovascular bundles it may entail. Use of a “veil” (Eur Urol 2007; 51:648-57), “curtain” (Eur Urol 2005; 48:938-45), or “high anterior release” (J Urol 2008;180:2557-64) technique of nerve sparing has also been demonstrated to have beneficial effects on potency.
Bladder neck reconstruction
Little data exist on the technique of bladder neck reconstruction during RALP, as many robotic urologists do not routinely perform it. The standard of care for open RRP is a tennis-racquet closure, which is our technique. To date, however, there have been no reports of tennis-racquet closure being performed robotically. We do not view the robot as a good unto itself, but, rather, as a tool that permits enhanced anatomic radical prostatectomy by improving vision and allowing angles of dissection not possible with open or straight laparoscopic instruments. Our data on this technique have been submitted for publication.