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Making the cut, precisely

Advanced Robotic Technique is a safe, effective and reproducible technique for removing the prostate. Ashutosh Tewari and Dr Abhishek Srivastava write. Celebrity survivors

health and fitness Updated: May 15, 2011 12:01 IST

Advanced Robotic Technique is a safe, effective and reproducible technique for removing the prostate. The procedure incorporates principles of both laparoscopic and open radical prostatectomy to lower invasiveness, pain and blood loss, which leads to quicker recovery. Urinary and sexual outcomes are not just dependent on technology but also on the surgeon’s experience and technical refinements.

Nerve-sparing techniques
A re-study of the pelvic neuroanatomy showed that the nerves are arranged all around the prostate as a neural hammock, which prompted us to call it ‘Tri-zonal Neural Hammock’. We then refined our technique of nerve sparing to avoid injury not only to the dominant (classical) neurovascular bundles but also to small (and potentially critical) components of this hammock, especially the delicate nerves that travel around and behind the prostate. Further refinements in nerve sparing came in terms of avoiding heated cautery instruments as nerves do not tolerate heat very well. Athermal Robotic Technique was thus developed to avoid heated cautery instruments.

Delicate tissue handling
Sexual dysfunction is the most common long-term side effect. Post surgery, penile hypoxia (oxygen deprivation in the penis) triggers a series of biochemical events that culminate in erectile dysfunction. These changes are associated with certain surgical steps and acute changes in blood supply. We hypothesised that by avoiding excessive tissue traction and overly aggressive dissection, hypoxia during surgery can be prevented. We tested this theory by maintaining tissue saturation above 85% during surgery with a novel tissue oximeter. The patients had less than 93% return to sexual function one year after surgery.

Next, we balanced the aggressiveness of nerve-sparing against risk cancer being left behind in the body, and developed a risk-stratified approach based on layers of periprostatic fascial dissection. This approach delivers early return of sexual and orgasmic function without compromising cancer control.

Nerve preservation

Apical (tip) dissection is a critical step since this area is the final common pathway for the exit of nerves. The visual angles are changed several times to allow identification of both bundles and their relationship with the external urethral sphincter. Careful dissection in this region also ensures good preservation of the mechanisms contributing to continence, which include complex ligaments and muscles. Armed with the findings of anatomic studies, we developed strategies for doing Athermal Robotic Technique for nerve sparing.

Patient selection
This procedure works best for men with clinically localised prostate cancer. Morbid obesity makes the surgery technically challenging, but we have used this procedure successfully in obese men, as well as men with other complications such as multiple abdominal surgeries and heart disease. All men have to undergo a thorough preoperative evaluation, which includes prostate-specific antigen testing, sexual function inventory, a quality of life score and an incontinence questionnaire.
Information about other existing diseases—such as stroke, brain aneurysm, diabetes, hypertension, respiratory disease and heart disease— is recorded. Patients are also questioned about their medical history, with emphasis on abdominal surgery, peritonitis, knee/hip surgery or peripheral neuropathy.

Surgical Team
The robotic team includes the console-side and patient-side surgeons. The operating surgeon sits at the console. After the patient-side team is scrubbed, they place the ports, present the operative field to the operating surgeon, and use suction to keep the field clean.

Post-operative care
Patients usually walk on the evening of the operation and go home either on the same day or the next morning. The catheter or splint is removed 4 to 7 days after surgery.

Dr Ashutosh Tewari and Dr Abhishek Srivastava in New York