European Urology

2.1. Patient population

From 2006 to 2008, 1151 patients underwent robotic radical prostatectomy by a single surgeon with a prior experience of 3188 (1200 open and 1988 robotic) radical prostatectomies. During this period, we incorporated three modifications into the published technique [1]. In January 2006, we introduced a modification of the veil nerve preservation; in January 2008, we began using a PST for bladder drainage; in May 2008, we started doing limited internal iliac node dissections (zone 2) in patients with a low probability of nodal metastases [2].

2.2. Description of the surgical techniques

An accompanying video shows the technical modifications.

2.3. Modified prostate fascia-preserving (veil) nerve sparing or superveil

We have described the veil technique of radical prostatectomy previously [1]. With this approach (n = 196), interfascial dissection is performed between the 1-o’clock position and the 5-o’clock position and between the 6-o’clock position and the 11-o’clock position, but not between the 11-o’clock position and 1-o’clock position, where the prostatic fascia is adherent to the capsule (Fig. 1). In the current modification, dissection was extended anteriorly, preserving this tissue, the pubovesical ligaments, and the dorsal venous plexus (see video). Where the planes did not separate easily with blunt dissection, sharp dissection was used with either the cold round-tip da Vinci scissors or the hot monopolar hook. The anterior dissection, if done properly, is under the dorsal vein complex. With favorable anatomy, the dissected complex formed an avascular hood, and control of the dorsal vein was not necessary; admittedly, such was not always the case.

Create Platinum Slide Series

Fig. 1 Tissue preserved during superveil nerve-sparing technique. Arrowheads correspond to preserved superveil and veil tissues.

2.4. Percutaneous suprapubic tube drainage

Starting in 2008, all patients with a waist circumference of <45 in who did not require bladder-neck reconstruction were offered percutaneous suprapubic tube bladder drainage (n = 285) (Fig. 2). Details of this technique have been published [3]. Briefly, the integrity of the urethrovesical anastomosis was confirmed intraoperatively with intravesical instillation of 250 ml of sterile saline. Under robotic visualization, a 14-French Rutner (Bard Medical, Covington, GA, USA) PST was percutaneously placed through the anterior abdominal wall. The bedside surgeon then inserted a 2-0 nonabsorbable polypropylene suture on a straight needle through the skin and abdominal wall adjacent to the PST. The console surgeon grasped the needle, placed a full-thickness horizontal mattress suture through the anterior bladder wall, and passed the needle back through the anterior abdominal wall, where it was grasped by the bedside surgeon. The anterior bladder wall was placed on traction, and the PST was inserted into the anterior detrusor wall between the limbs of the suture. Once the specimen was extracted and the pneumoperitoneum evacuated, the external suture was tied onto the skin over a sterile plastic button cinching the cystotomy to the anterior abdominal wall.

Create Platinum Slide Series

Fig. 2 Percutaneous suprapubic tube (PST) placement. PST is being placed by the bedside surgeon with robotic assistance from the console surgeon.

The PST was left to gravity drainage until postoperative day 5. Patients then clamped the tube, voided per urethrum, and measured postvoid residuals. After 48 h of voiding with residual urine <30 ml per void, the PST was removed. Cystograms were performed in patients with bladder pain or hematuria.

2.5. Limited internal iliac (zone 2) node dissection

For most of the study period, the template of node dissection that we used in patients with a 2007 Partin table–predicted [4] likelihood of nodal metastasis 0–1% was a limited external iliac and obturator (zone 1 of Mattei et al [2]) node dissection (n = 90) (Fig. 3). These were men who had a prostate-specific antigen (PSA) level <10 ng/ml, a primary Gleason score of 3 on biopsy (3 + 3 or 3 + 4), and a benign rectal examination. Starting August 2008, these patients preferentially underwent zone 2 dissection. Throughout the study, patients with palpable T2b–T3 disease, Gleason score of 8–10, or PSA >20 ng/ml underwent dissection of external iliac, obturator, and internal iliac nodes (zones 1 and 2), as described.

Create Platinum Slide Series

Fig. 3 Completed internal iliac/obturator lymphadenectomy on the left side compared with cadaveric dissection: (1) obturator artery; (2) internal pudendal artery; (3) inferior vesical artery; (4) superior vesical artery; (5) inferior gluteal artery; (6) superior gluteal artery; (7) lateral sacral artery; (8) internal iliac artery.

After the bladder was dropped from the anterior abdominal wall, the superior vesical artery was identified on the bladder and traced to its origin off the internal iliac artery. The ureter lies beneath the superior vesical artery and is protected because the dissection is distal to the artery. The tissue below the obturator nerve and along the lateral pelvic wall was carefully dissected to clear the obturator fossa. Finally, nodal tissue from the obturator fossa to the lateral surface of the bladder was removed. At the end of the dissection, the following vessels are seen: the internal iliac artery and vein, the obturator vessels and nerve, the superior and inferior vesical, the internal pudendal, superior and inferior gluteal, and the lateral sacral arteries (Fig. 3). Importantly, this dissection did not skeletonize the ureter or the external iliac vein. It also preserved the vascular branches to the bladder. Thus, the template of dissection is slightly different from the zone 2 dissection described by Mattei et al [2]. Grossly positive nodes were sent for frozen section; the rest were sent for permanent section and examined by a qualified uropathologist.

2.6. Patient follow-up

Patients who were operated in 2006 were started on on-demand phosphodiesterase type 5 inhibitors (PDE5-Is), but more aggressive rehabilitation was not initiated. Starting in 2007, penile rehabilitation was routinely recommended 4 wk after surgery for all patients with postoperative Sexual Health Inventory For Men (SHIM) scores <17. This included the use of intracavernosal injections or a vacuum erectile device, per patient preference. All patients were queried electronically at 4 wk, 3 mo, 6 mo, 12 mo, and annually thereafter with questionnaires (administered by a third party) that included SHIM and International Prostate Symptom Score (IPSS) scores and a question on pad usage. Only patients who had declined penile rehabilitation were included in this analysis. Functional outcomes were tabulated from the result of the questionnaires; information from direct patient interviews was not used.

2.7. Statistical analysis

Clinical information and pathologic data were obtained prospectively and were evaluated with descriptive statistics (SAS Institute, Cary, NC USA). Differences among groups were measured with the Fisher exact test. A two-tailed p-value <0.05 was considered significant.

3.1. Superveil

There were 171 patients with focal Gleason 6, PSA <4 ng/ml, and SHIM score >17 who underwent the superveil procedure (Fig. 4). The mean age of the patients was 55.3 yr, and the median follow-up was 18 mo (range: 3–36 mo) (Table 1). Twenty-four patients (14%) did not attempt sexual intercourse because of lack of partner interest, intolerance of PDE5-Is, expense of medication, or comorbidity. Eighteen patients (11%) submitted incomplete or incorrect postoperative SHIM data. Forty-four patients (26%) opted for immediate penile rehabilitation and 85 declined such treatment. 74 of 85 patients had used PDE5-Is, and 13 patients were current users. One patient with pathologic Gleason grade 7, T3a disease had a positive surgical margin, but no patient had a PSA recurrence.

Create Platinum Slide Series

Fig. 4 Flow chart for superveil patients.
SHIM = Sexual Health Inventory For Men; Super VIP = Superveil Vattikuti Institute Prostatectomy; Pre-op = preoperative; Post OP = postoperative; FU = follow-up.

Erectile function outcomes in the 85 patients who attempted sexual intercourse can be seen in Fig. 4 and Table 2. At a median follow-up of 18 mo, 94% had an erection strong enough for penetration, with a median SHIM score of 18 (Table 3). In patients with a minimum follow-up of 1 yr, 45% had no or mild erectile dysfunction (ED) (SHIM score of 18–25), 14% had mild-moderate ED (SHIM score: 12–17), 13% had moderate ED (SHIM score: 8–11), 20% had severe ED (SHIM score: 5–7), and 8% were impotent (SHIM score <5) (Table 2).

3.2. Percutaneous suprapubic tube

From January to December 2008, 285 of 309 patients underwent PST placement at the time of prostatectomy (Table 1). Placement of the PST added an additional console time of 2.3 h and operative time of 15 min. Given the option, 280 patients chose to have the Foley catheter removed 4–16 h after surgery. Five patients required urethral catheterization for dislodged PST early in our experience. The mean duration of PST catheterization was 7.6 d. Ten patients (3.5%) required PST drainage for a median of 10 d secondary to postvoid residual volumes >150 ml. In five patients who were unable to void after 10 d, the PST was removed and a urethral catheter was inserted for an additional 7–10 d.

Details of patient discomfort in the first 202 patients undergoing PST drainage have been published elsewhere [3]. Patients assessed catheter discomfort using a visual analog scale (0 = no discomfort and 10 = agonizing discomfort). On postoperative day 2, median discomfort level was 2, which fell to 0 on postoperative day 6 (Fig. 5). This was lower than values obtained with urethral catheterization [3]. The mean preoperative and postoperative IPSS scores were 11.3 (range: 0–35) and 8.9 (range: 0–32), respectively, in the PST patients (Table 1). Defining continence as 0–1 pads per 24 h, 90% of patients were continent at 90 d. At a mean follow-up of 9 mo, one patient had required urethral dilatation, one patient had required an optical urethrotomy, and two patients had urinary tract infections.

Create Platinum Slide Series

Fig. 5 Patient-reported pain scores for normal urinary catheter compared with pain scores for percutaneous suprapubic tube (PST).

3.3. Limited internal iliac node dissection

1006 patients (Table 4) underwent a limited zone 1 dissection (ie, external iliac and obturator), 90 underwent a limited zone 2 dissection (ie, internal iliac), and 55 underwent a zones 1 and 2 pelvic node dissection (eg, external iliac, obturator, internal iliac) [2]. On average, 6.4 nodes were removed with the zone 1 dissection, 5.5 nodes were removed with the zone 2 dissection, and 12.3 nodes were removed with zone 1 + 2 dissection (Table 4). In line with the 2007 Partin tables, the incidence of positive nodes was 0.5% (5/1006) in patients undergoing zone 1 dissection and 11% (6/55) in patients undergoing zones 1 and 2 dissection. Not shown is that five of six patients in the latter group had positive nodes in internal iliac, but not obturator nodes. This was the reason behind changing the template of node dissection in patients with low-risk disease. Although these patients had lower PSA levels than patients undergoing limited zone 1 dissection, the incidence of positive nodes was 13.7 times higher (6.7% vs 0.5%).

4.1. Superveil

In 2001, we and others described the existence of a neurovascular plexus around the prostate [6], [7], [8], [9], and [10]. This eventually led to the evolution [11], and [12] of the prostate fascia–sparing or veil nerve-sparing technique. This technique has been called interfascial dissection or high anterior release and has been adopted by some surgeons who perform open procedures [9], and [13]. Subsequently, studies have demonstrated that up to 10% of nerves lie between the 11-o’clock position and the 1-o’clock position on the anterior surface of the prostate [14]. We explored the feasibility of preserving these nerves in select patients. Compared with the lateral prostatic fascia, the anterior aspect of the prostate is predominantly fibromuscular, and clear separation from the prostatic capsule is difficult. Therefore, we perform this procedure only in patients with focal Gleason 6 disease who desire maximum nerve preservation. For want of a better term, we called this the superveil procedure. Because of this rigorous patient selection, we have had no PSA recurrences at up to 40 mo of follow-up.

As shown in Fig. 4, 94% of men who underwent the superveil operation declined penile rehabilitation and attempts at sexual intercourse were successful. In the most recent patients, such rates were reached within 6 mo of surgery. The quality of erections continued to improve with longer follow-up. Table 3 compares erectile function in the superveil and veil patients. While the average SHIM scores were similar for both groups of patients, the superveil patients were able to achieve intercourse earlier than veil patients.

A rigorous comparison of erectile function outcomes is beyond the scope of this paper; however, these results approximate results reported previously. In our first two reports of the veil technique, 51% and 49% of men reported SHIM scores >21 without PDE5-Is, and 97% and 96% of men were able to have intercourse at a minimum follow-up of 12 mo [11], and [15]. In the current paper, the corresponding percentages were 45% and 92% at median follow-up of 24 mo. However, 86% of the original patients [11] and 71% [15] of the original patients, respectively, achieved normal erections with PDE5-Is, whereas we did not see such a benefit in this study. This may be due to several factors. In 2006, we started an early penile rehabilitation program. The current study included only patients who refused penile rehabilitation. Inclusion of these patents would have improved median SHIM scores by 4 points, bringing postoperative scores to 22. Furthermore, 14% (24/171) of the patients did not attempt sexual intercourse, and 60% of the patients had comorbidities that are associated with ED (data not shown). Additionally, compliance with PDE5-I use was not assessed in this study. Thus, it is likely that these patients were not as well selected as the earlier patients.

It is unclear how sparing a few additional nerves can lead to an earlier return of erectile function; however, the superveil dissection is performed further away from the primary neurovascular bundle than in the veil operation. Perhaps this difference leads to less neurapraxia.

Finally, we have been criticized for the use of monopolar or bipolar cautery during nerve sparing. In our experience, the interfascial plane is very vascular or adherent to the prostate capsule in about 50% of patients [16]. In these patients, the monopolar hook, used as a blunt dissector on the anterolateral surface of the prostate, allows us to get into the plane easier than the other da Vinci instruments. This approach was also used in our earlier studies, so we do not believe that it can explain apparent differences in outcomes.

4.2. Percutaneous suprapubic tube

Catheter discomfort is a common complaint among patients after radical prostatectomy. In a self-administered questionnaire, 22 patients (19%) had moderate bother from incisional pain and urethral catheterization after open radical prostatectomy, and 54 patients (46%) had severe bother [17]. Recently, Tewari et al described the use of a modified suprapubic catheter with an extension that serves as a splint for the urethrovesical anastomosis in 10 patients undergoing robotic prostatectomy [18]. They found a decrease in penile pain but not in bladder spasms. Encouraged by these results, we investigated the feasibility of robotic radical prostatectomy using a standard PST for bladder drainage, without urethral stenting beyond 24 h [3].

Our preliminary results suggest that PST placement with early urethral catheter removal is feasible and offers increased patient comfort. By postoperative day 6, all patients had no discomfort with the PST. Furthermore, patients are not at any greater risk of urethral strictures or bladder-neck contractures at 6 mo follow-up. Detailed results are reported elsewhere [3].

4.3. Limited internal iliac node dissection

The role of node dissection in patients undergoing radical prostatectomy is unclear. While there is consensus that a complete node dissection should be done in patients with aggressive prostate cancer [19], [20], and [21], many surgeons perform a limited dissection of the external iliac nodes in patients with low-risk prostate cancer [22]. In fact, some surgeons suggest omitting it altogether in patients with early prostate cancer [23], and [24].

Our study was not designed to resolve this controversy. We continue to do a complete dissection in patients with aggressive cancer (Partin probability >5%) [19], [20], and [21]. However, in patients with a low probability of node disease (Partin table prediction 0–1%), we found positive nodes in the internal iliac/obturator region (zone 2) 13.7 times more often than in the external iliac/obturator region (zone 1). Thus, a zone 2 dissection has become our preferred template in patients with low-risk prostate cancer.

There are important differences between our technique and those reported by others [2], [19], and [21]. To avoid inadvertent ureteric injury, we do not dissect between the ureter and the superior vesical artery; however, there is very little tissue there, and we are not aware of any reported instance where the only positive node is in that location. Additionally, we do not remove the branches from the pelvic arteries to the bladder but tease nodal issue from around them. This may result in less complete node clearance than that reported by others. Our nodal yield, however, accords with a recent report from the Studer group [2]. In 34 patients undergoing single photon emission computed tomography and/or computed tomography and/or magnetic resonance imaging followed by complete surgical nodal mapping, these surgeons found a total of 120 nodes (mean: 3.5) in the external iliac/obturator and 81 nodes (mean: 2.4) in the internal iliac regions.

In deciding whether or not to do a node dissection, the risks and benefits of the procedure must be balanced. Our analysis suggests that the removal of additional nodes in zone 1 would have resulted in positive nodes in an additional 0.5% of patients. In a randomized clinical trial, Clark et al found that the complication rate, although low, was three times as high in patients who underwent an extended node dissection [22]. To us, the marginal increase in node yield does not justify doing an extended node dissection in patients whose probability of nodal disease is as low as 1%.