Designer Robotic daVinci Prostatectomy
Dr. Ramin believes that a surgeon should have enough skill and experience to taylor a robotic surgery to the each patient's individual specifications. Therefore, he does not perform the same type of Robotic Prostatectomy on every person. Many subtle and not so subtle techniques are employed to make the robotic surgery more successful for each individual patient.
Dr. Ramin designs an individualized robotic surgical plan specific to each patient. This plan is based on a number of parameters:
- Each individual patient's type, location, amount of cancer;
- Each patient's prostate size and anatomy;
- Each patient's pre-surgical voiding function
- Each patient's pre-surgical sexual function.
The various types of techniques and procedures that may be used in a given patient's surgery are listed below. Dr. Ramin discusses with his patients in detail which types of variation are best suited for that individual patient.
These technical variations are listed below, followed by detailed descriptions
DESIGNER ROBOTIC DAVINCI PROSTATECTOMY
- Nerve Sparing Techniques
- Intrafascial Nerve Sparing
- Extrafascial Nerve Sparing
- Wide Resection Technique
- Pelvic Lymph Node Removal
- Anti-Incontinence Techniques
- Bladder Neck Sparing
- Urethral Muscle Sparing
- Peritoneal Flap Urethral Sling
Nerve Sparing Techniques and Preservation of Sexual Function
The nerves that are essential for a man to obtain and maintain erections run along and in close proximity to the right and left of back side of the prostate gland. A nerve sparing prostatectomy refers to removal of the prostate gland while saving these nerves, in order to ensure good sexual function after surgery. In order to perform this surgery successfully, the surgeon must literally peal the tissues that contain the nerves off of the prostate.
This technique is offered to men with prostate cancer that has not penetrated the tissues around the prostate that contain these nerves. Dr. Ramin performs two distinct types of nerve sparing techniques: Intrafascial Nerve Sparing and Extrafascial Nerve Sparing.
Intrafascial Nerve Sparing
This technique involves opening a layer of tissue on the prostate called the lateral Prostatic Fascia. After this layer is opened, then the tissues containing the nerves are dissected off of the right and left sides of the prostate. This technique removes the most amount of nerve tissue off the prostate, leaving in the body the entire tissue that contains these nerves. This technique removes the entire prostate, without removing any additional tissue with the prostate. While this technique allows for the best chance at preservation of sexual function post operatively, it by its nature leaves very little extra tissue with the prostate.
Depending on the amount of cancer on each side of the prostate and the level of a patient's sexual function pre-operatively, Dr. Ramin may perform this technique on one or both sides of the prostate. This technique is offered to patients who have very early stage prostate cancer, with no cancer beyond the outer covering (capsule) of the prostate.
Extrafascial Nerve Sparing
This technique involves keeping the lateral prostatic fascia and the anterior leaflet of the Denonvalier's fascia intact, while sweeping the tissues that contain the nerves off the prostate. This technique allows for more tissue to be removed with the prostate, thereby leaving slightly less tissue in the patient's body. A few millimeters of additional tissue surrounding the prostate is removed with the prostate, in order to remove any cancer cells that may have penetrated through the outer covering (capsule) of the prostate. This technique allows the surgeon to perform a nerve sparing procedure, while also allowing for the margins of resection to be free of cancer. By its nature, this technique does result in removal of a small percentage of the nerves that help with sexual function, but does not result in removal of all the nerves.
Depending on the amount of the cancer on each side of the prostate and the level of a patient's sexual function pre-operatively, Dr. Ramin may perform this technique on one or both sides of the prostate. This technique is offered to patients with slightly higher amount of tumor (higher tumor volume) on one side or both sides of the prostate, as compared to the patients described in the previous section.
The advantage of this technique is that it gives the patient an excellent chance of cure from prostate cancer, while still providing the patient with a good chance at recovery of potency.
Wide Resection Technique:
If a particular patient's cancer has travelled extensively beyond the outer covering of the prostate (prostate capsule), it is likely that the cancer has invaded the tissues that contain the nerves for sexual function. In such patients, any nerve sparing technique is liable to leave cancer behind.
In such circumstances, Dr. Ramin may recommend a wide resection technique which removes the prostate with a wide margin containing all tissues around the prostate, including the nerve bundles, the vascular bundles, all the fascial layers and fat surrounding the prostate. Maximal amount of tissue surrounding the prostate is removed, in order to allow for margins of resection to be free of prostate cancer.
This technique may be used on one side or both sides of the prostate, depending on the amount and grade of tumor on each side of the prostate. Therefore, there are instances, where Dr. Ramin recommends a wide excision technique on one side and a nerve sparing on the other side.
How do we know if a patient's prostate cancer has travelled beyond the capsule? If there is extension beyond the capsule, how extensive is it?
A number of factors are examined by Dr. Ramin, in order to answer this question.
- Amount or Volume of Prostate Cancer: The higher the number of areas that show cancer on a biopsy, the higher the likelihood for prostate cancer penetration into the nerve bundles. Furthermore the higher the percentage of cancer per area of biopsy, the higher the chance for nerve involvement.
- Example: Patient's biopsy shows one of twelve biopsy cores positive for cancer: It is unlikely that this patient has cancer penetration in the nerve bundles
- Example: Patient's biopsy shows six of twelve cores positive for cancer: It is more likely the patient has cancer penetration in the nerve bundles
- Gleason Grade: The higher the gleason grade, the higher the likelihood of cancer penetration into the nerve bundles.
- Prostate Nodule: Areas of prostate nodularity, especially if correlated to the biopsies showing cancer at the nodular sites will have higher likelihood of cancer penetration in the nerves.
- Radiologic testing:
- MRI: MR spectroscopy, Endocoil MRI may aid in determining extension in the nerve bundles
- Prostate Doppler: Overall not a very reliable way to determine extension
- CT Scan: While helpful in determining spread to other organs, CT is not helpful in determining extension of prostate cancer into nerve bundles.
Fortunately, saving the nerves is not an all or none concept. There are two bundles of nerves attached to the outer layer of the prostate, one on the left, and one on the right. Dr. Ramin employs various techniques, as described above, on each side of the prostate to increase the likelihood of complete cancer removal, while giving the best chance at excellent quality of life.
Removal of Pelvic Lymph Nodes
Robotic or daVinci Laparoscopic Pelvic Lymph Node Dissection (Removal) is an important part of treatment of patients undergoing daVinci Prostatectomy. There is a misconception among some physicians and patients that a major disadvantage of robotic or daVinci Prostatectomy is the inability to perform a lymph node removal with this technique. Dr. Ramin has performed well over 750 robotic or daVinci Lymph Node Dissections at the time of prostatectomy. He recommends that pelvic lymph node removal be peformed on patients with prostate cancer, and routinely performs it on almost all patients undergoing daVinci Prostatectomy.
It is important for you to know the following facts in regards of Pelvic Lymphadenectomy (removal):
- Lymphadenectomy does not remove all the pelvic lymph nodes: there are hundreds of lymph nodes throughout our body, including the pelvic area. The packet of tissue that is removed during this surgery on average contains 5 lymph nodes from each side of the pelvis.
- Lymphadenectomy will not result in loss or weakening of the immune system
- Lymphadenectomy is done as a staging tool: It allows the patient and his physician to know whether there has been microscopic cancer spread to the lymph nodes or not. If there has been spread, then the lymph node removal has allowed for earlier start of additional treatment for the patient.
- Lymphadenectomy does require higher skill level to perform, and may not be offered by all physicians that perform robotic prostate surgery.
Incontinence refers to the inability to control urination and the bladder after prostate cancer surgery. Patients with incontinence after prostate surgery wear pads or diapers, usually for a short period of time, until their natural bladder control return. Dr. Ramin employs three surgical techniques in order to shorten the time to bladder control recovery.
Bladder Neck Sparing Technique
This technique involves separating the bladder from the prostate, without disturbing the circular muscles that wrap around the neck of the bladder. The prostate gland is normally attached to the bladder. The bladder muscle fibers that are immediately attached to the prostate are called the bladder neck fibers. The function of these muscles is to keep urine from leaking out of the bladder into the prostate without a person's control. During prostate cancer surgery, many times these muscles are cut or transected in order to free the prostate from the bladder. Dr. Ramin employs a technique called "Bladder Neck Sparing Technique", in which the muscles are not cut or transected. The Prostate gland's attachment to the bladder at the bladder neck is literally pealed away, thereby saving or sparing the integrity of these muscle fibers. This technique allows for faster recovery of bladder control after prostate cancer surgery. However, it is technically more difficult than transecting through the muscles to separate the prostate from the bladder.
Urethal Muscle Sparing Technique
The muscles that wrap around the urethra help to preserve bladder control and aid in faster recovery of continence after surgery. Dr. Ramin meticulously sweeps these muscles off the prostate and the dorsal vein complex before separating the urethra from the prostate. These muscles are deeply imbedded underneath the pubic bone. The robotic instrumentation makes it more possible to view and preserve these muscles as compared to open prostate surgery.
Urethral Sling Procedure Using Peritoneal Flap
This technique was invented and brought into clinical practice by Dr. Ramin in December 2008. Dr. Ramin uses the patient's natural tissue, the peritoneal lining of the bladder, to build a sling underneath the urethra. This sling then is used to cradle and support the urethra, effectively placing it back in its normal anatomic position and angle, after the prostate has been removed. There are no additional incisions on the patient's body to perform this part of the procedure. It all performed in the same surgical field as the prostate surgery. This technique allows for faster recovery of continence after robotic daVinci Prostatectomy. It is currently being performed by Dr. Ramin on most of his patients. Most patients who undergo daVinci Prostatectomy are good candidates for this procedure.