Vattikuti Institute Prostatectomy: Technical Modifications in 2009

BackgroundSince we last published our technique of robotic prostatectomy, we have introduced three technical refinements: superveil nerve sparing, bladder drainage with a percutaneous suprapubic tube (PST), and limited node dissection of the obturator and internal iliac nodes in preference to the external iliac nodes in selected patients.ObjectiveTo describe selection criteria, to explain the three techniques, and to evaluate functional and oncologic results.Design, setting, and participantsSingle-institution study of 1151 radical prostatectomies performed from 2006 to 2008 by one surgeon.Surgical procedureThe superveil nerve-sparing technique spares nerves from the 11-o’clock position to the 1-o’clock position. The bladder is drained with a PST rather than a urethral catheter. For low- or intermediate-risk disease, limited lymphadenectomy concentrates on the internal iliac and obturator nodes, excluding the external iliac lymph nodes.MeasurementsErectile function and patient comfort were evaluated using questionnaires administered by a third party. Lymph node yield was quantified by a qualified uropathologist.Results and limitationsAt 6–18 months after surgery, 94% of men who attempted sexual intercourse were successful with a median Sexual Health Inventory For Men (SHIM) score of 18 out of 25. PST bladder drainage resulted in less patient discomfort; visual analog scores were 2 at 2 days after prostatectomy and 0 at 6 days after prostatectomy. The modified lymphadenectomy harvested few overall nodes, but it increased the yield of positive nodes >13-fold in patients with low-risk stratification (6.7% compared with 0.5%).ConclusionIn this single-institution, single-surgeon study, these modifications improved erectile function outcomes, decreased catheter-associated discomfort, and enhanced the detection of positive nodes.