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ABSTRACT: To analyze the outcomes of the first 100 patients undergoing robotic radical prostatectomy by a single surgical team.
From August 2001 to May 2002, we performed robotic radical prostatectomy in 100 patients with localized prostate cancer. The mean age was 60 +/- 0.67 years (SEM), the body mass index 27.5 +/- 0.35, the preoperative prostate specific antigen concentration 7.2 +/- 0.86 ng/mL, and follow-up 5.5 +/- 0.24 months. Thirty-eight patients also underwent pelvic lymph node dissection. We used the da Vinci surgical system and a subperitoneal approach (the Vattikuti Institute Prostatectomy; VIP). This is a prospective outcomes analysis of these patients.
The mean operating time was 195 +/- 5.0 minutes, and the mean blood loss was 149 +/- 11.8 mL. No patient required blood transfusion. The stages of the cancers were pT(2a) in 21, pT(2b) in 64, pT(3a) in 5, pT(3b) in 9, and pT(3b)N(1) in 1. The positive surgical margin rate was 15%. At 1, 3, and 6 months, the continence rates were 37%, 72%, and 92%, respectively, and the potency rates were 11%, 32%, and 59%.
The VIP is a safe operation with excellent operative parameters, low morbidity, and good surgical margins. The early functional results are promising.
Journal of Endourology 12/2003; 17(9):785-90. · 1.85 Impact Factor
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ABSTRACT: We have performed more than 250 radical prostatectomies using the da Vinci (Intuitive Surgical, Mountain View, California) surgical system. Our initial cases were done using the classic Montsouris approach. However, after gaining familiarity with the robot we modified our technique to reflect our experience with open radical retropubic prostatectomy. We detail the Vattikuti Institute prostatectomy technique that we currently use.
The robotic technique requires 2 teams, namely a skilled laparoscopic team at the patient and a skilled open surgeon at the console. Dissection is started anterior to the bladder and it continues extraperitoneally. The endopelvic fascia is opened and the dorsal vein complex is secured. The apex of the prostate is dissected free, releasing the neurovascular bundles at the apex. The bladder neck is then incised, and the seminal vesicles and vasa are transected. Posterior dissection is done within the posterior layer of Denonvilliers' fascia, preserving the neurovascular bundles and lateral prostatic fascia. The apex is transected and frozen sections are obtained from the parietal margins. Vesicourethral anastomosis is formed with 2 continuous sutures.
In the last 100 cases mean operative time was 2.5 hours and average blood loss was 150 ml. (range 25 to 525 cc.). Median specimen Gleason score was 7 and mean tumor volume was 7 cc. Four patients had a positive surgical margin, which was focal in 3. Of the patients 95% were discharged home within 23 hours. Mean catheterization time was 4.2 days.
Vattikuti Institute prostatectomy is a precise and safe minimally invasive technique of radical retropubic prostatectomy.
The Journal of Urology 07/2003; 169(6):2289-92. · 3.75 Impact Factor
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Ashutosh Tewari,
James O Peabody,
Melissa Fischer,
Richard Sarle,
Guy Vallancien,
V Delmas,
Mazen Hassan,
Aditya Bansal,
Ashok K Hemal,
Bertrand Guillonneau,
Mani Menon
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ABSTRACT: To provide a detailed description of the steps involved in a laparoscopic radical prostatectomy in relation to the complex neurovascular anatomy of the male pelvis. AIM AND HYPOTHESIS: We aimed at delineating the neurovascular anatomy to assist in nerve preservation during laparoscopic and robotic radical prostatectomies.
A team of urologists and an anatomist performed anatomic dissections of 12 male cadavers using a combination of laparoscopic equipment, magnification, and open surgical dissection. Each step involved in laparoscopic prostatectomy was reviewed in relation to the possible impact the step could have on the neurovascular bundles.
Dissections were performed systematically to mimic various steps of laparoscopic and robotic prostatectomy. The neurovascular bundles were identified and correlated with video images of actual surgery. This enabled us to construct computer simulations and show the actual nerves on the operative pictures. We specially unraveled the relationship between neurovascular bundles and lateral pelvic and Denonvillier's fascias, both of which enclose and hide these important structures. The course of the bundles was traced from its origin at pelvic plexus to its distal course along the urethra. We also showed the important relationship between pelvic plexus ganglions and seminal vesicles to illustrate the vulnerability of these nerves to thermal, electrical and/or crush injury during seminal vesicle and prostatic pedicle dissections. The importance of additional fine neural plexus along the posterior and antero-lateral surface of the prostate was shown by both gross anatomical and microscopic images. The distal precarious location of the bundles was illustrated by dissections showing anteriorly lifted prostate.These anatomico-operative correlations have not been published for laparoscopic and robotic prostatectomies, which differ significantly in its visual angles, magnifications and sometimes three-dimensional (3D) visualization from its open counter part.
Laparoscopic and robotic radical prostatectomy provides exposure and visualization of male pelvis not previously appreciated. It is only through a careful reexamination of the anatomy of the male pelvis, in the context of this new procedure, that the improvements in visualization and exposure benefit the surgeon. Our work provides a detailed map relating to operative steps to aid the surgeon in the performance of a nerve sparing robotic and laparoscopic radical prostatectomy.
European Urology 06/2003; 43(5):444-54. · 8.49 Impact Factor
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ABSTRACT: The Vattikuti Urology Institute has been developing a robotic prostatectomy system for the management of prostate cancer. This technique is based on the scientific foundations of Walsh's anatomic prostatectomy. Two hundred fifty patients with clinically localized prostate cancer have undergone this technique. Preoperative, operative, and postoperative parameters were collected, and functional outcomes using previously validated quality-of-life instruments were evaluated. The mean operating time for these patients was 2.5 hours (165 and 135 minutes with and without lymphadenectomy, respectively), and the average blood loss was 150 mL. The median specimen Gleason score was 7, and the mean tumor volume was 7 mL. Four patients had a positive surgical margin (three unifocal, one multifocal). Ninety-five percent of the patients were discharged within 23 hours, and the mean catheterization time was 4.2 days. The complication rate was 4%. Approximately 78% of the patients had intact erectile response and 96% achieved continence by the sixth month after surgery. The robotic prostatectomy system is a safe and effective operation for the management of prostate cancer.
Current Urology Reports 05/2003; 4(2):119-23.
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ABSTRACT: We have performed >350 robotic radical prostatectomies in the last 2 years. A single surgeon (MM) performed 250 of these procedures using a technique developed at our institution, the Vattikuti Urology Institute. This article summarizes the technical highlights and interim results of the Vattikuti Institute Prostatectomy (VIP) technique. We prospectively collected baseline demographic data, such as age, race, body mass index (BMI), serum prostate-specific antigen values, prostate volume, Gleason score, percentage cancer, TNM clinical staging, and comorbidities. Urinary symptoms were measured with the International Prostate Symptom Score, and sexual health with the Sexual Health Inventory of Males. In addition, patients received the Expanded Prostate Inventory Composite at baseline and at 1, 3, 6, 12 and 18 months after the procedure via mail. Data collection is complete on 200 of the first 250 patient cases. Gleason score >or=7 was noted in 40% of patients. The average BMI was high (28), and 86% patients were classified as pathologic stage pT2a to pT2b. The mean operative time was 160 minutes and the mean blood loss was 153 mL. No patient required blood transfusion. At 6 months, 82% of the men who were <60 years of age and 75% of those >60 years of age had return of sexual function, and 64% and 38%, respectively, had sexual intercourse. At 6 months, 96% patients were continent.
Urology 04/2003; 61(4 Suppl 1):15-20. · 2.43 Impact Factor
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International Urology and Nephrology 02/2003; 35(1):107-13. · 1.47 Impact Factor
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ABSTRACT: To develop a mathematical model to predict prostate biopsy outcome using readily available clinical variables.
A total of 319 men (78% African American) undergoing transrectal ultrasound-guided prostate biopsy were prospectively studied. The parameters collected included age, race, prostate-specific antigen (PSA) level, PSA density (PSAD), digital rectal examination findings, biopsy history, prostate volume (by transrectal ultrasound), and ultrasound findings. Models were constructed using multivariate logistic regression (LR) analysis and back-propagation artificial neural networks (ANNs). Patient data were randomly split into five cross-validation sets and used to develop and validate the LR and ANN models.
Of the 319 men, 39% had a positive biopsy. The mean patient age was 65.1 +/- 8.3 years, with a mean PSA level of 12.6 +/- 24.9 ng/mL and a mean PSAD of 0.31 +/- 0.66 ng/mL/cm(3). Univariate analysis indicated a significant difference in age, PSA level, PSAD, free PSA, digital rectal examination findings, TRUS lesion, and biopsy history between the positive and negative biopsy groups (P <0.01). The mean area under the receiver operating characteristic curve (AUROC) for the five LR models was 0.76 +/- 0.04 (range 0.71 to 0.81). The median LR AUROC was 0.76, with a corresponding specificity of 0.13 at a sensitivity of 0.95. The mean AUROC for the five ANN models was 0.76 +/- 0.04 (range 0.71 to 0.83). The median ANN AUROC was 0.76, with a corresponding specificity of 0.21 at a sensitivity of 0.95.
Two models (LR and ANN) that predict outcome with high efficiency (AUROC = 0.76) were constructed from a contemporary, prospective database. Such models may be useful to patients and physicians alike when assessing the diagnostic strategies available to detect prostate cancer.
Urology 11/2002; 60(5):831-5. · 2.43 Impact Factor
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ABSTRACT: Robotic assistance may enhance the precision of anatomic dissection and increase the feasibility of performing laparoscopic radical prostatectomy for most surgeons. We performed a prospective comparison of 30 consecutive patients undergoing conventional radical retropubic prostatectomy (RRP) and 30 initial patients undergoing robot-assisted anatomic prostatectomy (RAP) at our institution.
The study design was a prospective nonrandomized comparison of anatomic RRP performed using the technique of Walsh and RAP performed with the da Vinci surgical system. We evaluated the baseline patient and tumor characteristics (age, body mass index, serum prostate-specific antigen, Gleason score, and clinical stage), intraoperative parameters (operative time, blood loss, and need for transfusion), postoperative parameters (pain score, hospitalization duration, catheter duration), histopathologic parameters, and complications in the two groups.
The preoperative parameters were comparable for both groups of patients. The mean setup time for RAP was 0.95 hours. The mean operating time was 2.3 hours for RRP and 4.8 hours for RAP (P <0.001). One patient required conversion from RAP to RRP because of a lack of progress. The mean blood loss was 970 mL for RRP and 329 mL for RAP (P <0.001). The drop in hemoglobin was greater in the RRP group (4.4 versus 1.2 g in RAP; P <0.05). The mean pain score on postoperative day 1 was 7 in the RRP group and 4 in RAP group (P = 0.05). The mean hospital stay was 56 hours in the RRP group and 36 hours in the RAP group (P value not significant). Sixty-three percent of the RAP and 0% of the RRP groups were discharged within 23 hours (P <0.001). The mean duration of postoperative catheterization was 14 days for the RRP and 11 days for the RAP groups (difference not significant). The pathologic stage, margin status, and prostate-specific antigen values were not different between the two groups. The setup time, operative time, blood loss amount, and catheterization duration were significantly reduced after the first 20 patients.
Currently, RAP is a longer procedure than RRP. However, the blood loss is minimal and patients feel less pain and are discharged earlier from the hospital. In our hands, the margin status and complication rates were comparable for both techniques.
Urology 11/2002; 60(5):864-8. · 2.43 Impact Factor
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ABSTRACT: Robotic radical prostatectomy is a new procedure for treating prostate cancer. Many centers are attempting this new modality but a detailed description of the technique has not yet been published. We report the technique as performed at the Vattikuti Urology Institute.
At Vattikuti Urology Institute, we have performed more than 30 such operations and have standardized the technique for safe and reproducible treatment of prostate cancer. We collected the patient data and surgical logs to improve and standardize this procedure. We recorded the operation and made relevant modifications after reviewing the recordings to improve the outcome.
The operation was developed on the scientific foundations of anatomic radical prostatectomy as described by Walsh and the laparoscopic prostatectomy developed at Montsouris. Our technique differs from these procedures because of the need for two surgical teams and the use of fine, endo-wrist instruments with three-dimensional stereoscopic visualization. We describe the patient setup, positioning, port placement, preparation of the robot, docking of the arms, and the surgical steps of performing anatomic prostatectomy with robotic assistance.
This report describes the current technique of robotic prostatectomy as developed at the Vattikuti Urology Institute.
Urology 11/2002; 60(4):569-72. · 2.43 Impact Factor
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ABSTRACT: The technique of laparoscopic radical prostatectomy is difficult to master and is associated with a steep learning curve. We hypothesized that a structured approach to establishing a laparoscopic prostatectomy program would diminish complications during the learning process and that robotic technology would be useful in learning the operation.
A structured laparoscopic radical prostatectomy program was introduced at the Vattikuti Urology Institute on October 23, 2000. One of 2 surgeons with a combined experience of more than 500 laparoscopic radical prostatectomies performed or supervised the first prostatectomies, training a third surgeon with extensive "open" surgical skills but no laparoscopic experience. The "trained" surgeon then started performing the operation independently with robotic assistance. The results of this approach were analyzed at the end of 12 months.
We performed 48 laparoscopic radical prostatectomies and 50 robot assisted prostatectomies within the 12-month period. The preoperative and intraoperative demographical variables were comparable in both groups as were the operative times, changes in hemoglobin concentrations, durations of hospitalization, positive margin rates and overall complication rates. All measured parameters were comparable to the "best-in-class" values for laparoscopic radical prostatectomy reported in the literature.
A structured approach minimizes complications during the establishment of laparoscopic radical prostatectomy program. Robotic assistance helps skilled "open" surgeons learn the technique of laparoscopic radical prostatectomy.
The Journal of Urology 10/2002; 168(3):945-9. · 3.75 Impact Factor
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ABSTRACT: Prostate cancer remains the most commonly diagnosed noncutaneous malignancy in American men. Currently, there are 3 standard treatment options available to men with early prostate cancer: expectant management, radiation therapy, and radical prostatectomy. Although a number of studies have evaluated survival after treatment for early prostate cancer, the optimal choice of therapy for any given patient remains a difficult decision and requires the consideration of a variety of patient and tumor factors. The final selection of therapy for early prostate cancer should be based on an informed discussion between the physician and patient. To accomplish this goal, patients must be made familiar with the pertinent factors that affect survival. We review the factors most relevant for patients to understand as they consider their treatment options for early prostate cancer and summarize the data for physicians who counsel them.
Seminars in Urologic Oncology 03/2002; 20(1):39-44.
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The National medical journal of India 22(4):184-7. · 0.60 Impact Factor
