Vattikuti Institute prostatectomy: technical modifications in 2009.

BACKGROUND: Since 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.
OBJECTIVE: To describe selection criteria, to explain the three techniques, and to evaluate functional and oncologic results. DESIGN, SETTING, AND PARTICIPANTS: Single-institution study of 1151 radical prostatectomies performed from 2006 to 2008 by one surgeon. SURGICAL PROCEDURE: The 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. MEASUREMENTS: Erectile function and patient comfort were evaluated using questionnaires administered by a third party. Lymph node yield was quantified by a qualified uropathologist. RESULTS AND LIMITATIONS: At 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%).
CONCLUSION: In this single-institution, single-surgeon study, these modifications improved erectile function outcomes, decreased catheter-associated discomfort, and enhanced the detection of positive nodes.