ROBOT-ASSISTED RADICAL LAPAROSCOPIC PROSTATECTOMY WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER WINSTON-SALEM, NC

Transcription

1 ROBOT-ASSISTED RADICAL LAPAROSCOPIC PROSTATECTOMY WAKE FOREST UNIVERSITY BAPTIST MEDICAL CENTER WINSTON-SALEM, NC 00:00:08 ANTHONY ATALA, MD: I would like to welcome you to our webcast from Wake Forest University Baptist Medical Center. I am Anthony Atala, Chair of the Department of Urology. We are fortunate in our department to have with us one of the pioneers in urologic robotic surgery, Dr. Ash Hemal. You will see Dr. Hemal perform a radical prostatectomy with a robot, a procedure being performed internationally, that he helped develop. Our two other specialists in urologic oncology, Dr. Joseph Pettus and Dr. Karim Kader, will guide you through the procedure and take your questions. Let's go to the operating room and see this amazing team at work. 00:00:58 A. KARIM KADER, MD, PhD: Hello and welcome to Wake Forest Baptist Medical Center. My name is Dr. Karim Kader. We're broadcasting to you live from O.R. 32, where we'll have a real-time demonstration of the robot-assisted laparoscopic prostatectomy, performed by a pioneer in this field, Dr. Ashok Hemal. I'm joined with me today with Dr. Joe Pettus. Together we are assistant professors of urology here at Wake Forest and specialize in urologic oncology. Well, without further ado, let's cut to the live surgery, where Dr. Hemal is right now dissecting out the anterior bladder neck. Before we talk about too much else, I want to remind all our viewers that they can ask questions directly here to the OR by clicking on the MDirect Access button on your screen. Dr. Hemal? 00:01:50 ASHOK K HEMAL, MD: Yeah. Hello Dr. Kader and Dr. Pettus. Welcome viewers. As you know, when you do have a cancer prostate, the goal of treatment of cancer prostate is to do a radical prostatectomy. And we have three goals: one, to excise the cancer completely and provide urinary incontinence and to maintain to have an erection after the surgery, if patients have these abilities before the surgery. What I have done so far, you can appreciate that here is the prostate gland. And you know, this prostate is a little big. Because of that, it's occupying all of the pelvis. And here you can appreciate, because of the narrow pelvis, you see this is the dorsal venous complex. I have tied the dorsal venous complex, and also I have lifted the urethra and sphincter complex entirely, so it helps in achieving early continence in a better way. If you look posteriorly, I have already dropped the bladder off the anterior abdominal wall. Let me go closer so you can appreciate. This is the prostate here going right up to there, and this is the apex of the prostate, which is attached to the urethra. And this part is the urinary bladder, that [box] that is for the urine. So now I'm going to start. I'm going to divide the bladder neck and over to Dr. Kader. 00:03:20

2 A. KARIM KADER, MD, PHD: Well, Dr. Hemal, that is a beautiful dissection, I've got to say. Clearly this type of work cannot be done in isolation and I want to introduce some members of our team. On the patient's right-hand side is Dr. Michael [Traver]. He is our chief resident right now. And he has gained significant experience already in robotic surgery and is hoping to continue this next year. On the patient's left-hand side, there is Dr. Jacob Richard. He is a third-year resident and will play an integral part in this section on the left-hand side. Our scrub nurse today is Dr. Crystal Combs. Crystal, why don't you turn around and wave to the camera? Okay, there's Crystal. Our circulating nurse is Dr. Bob or Bob Sandler. I just gave you a promotion. Okay, and anesthesia today is being providing by Mike May, our CRNA here. 00:04:20 ASHOK K. HEMAL, MD: And Dr. [Whalen]. 00:04:21 A. KARIM KADER, MD, PHD: Okay, so why don't we cut back to the surgery where we're going to be starting with the anterior bladder neck dissection. 00:04:28 ASHOK K. HEMAL, MD: What I have done so far, you can appreciate. I am trying to go to the anterior bladder neck. And here very well you can appreciate the prostate right there. And I'm coming to the lateral part of the bladder here. These are the, you know, fat, and it also has some of the vessels. So, can you suck here? So I'm trying to go into the midline. 00:04:55 A. KARIM KADER, MD, PHD: Well, why don't we cut right now 00:04:57 ASHOK K. HEMAL, MD: Usually, at this step we keep a catheter inside so when I cut the anterior bladder neck so I can feel the catheter, I can see the catheter very well and very soon you are going to see the catheter right there. So you can appreciate the catheter right there. 00:05:19 JOSEPH A. PETTUS, MD: This is a very typical patient we have here. This gentleman is a 65-year old man who has a history of just high cholesterol. His past medical history is significant that he has lower urinary symptoms, or obstructive-like symptoms, that have not resolved with medication. He has what we call Gleason 6 prostate cancer. 00:05:43 ASHOK K. HEMAL, MD: Jake, can you hold this? 00:05:45 JOSEPH A. PETTUS, MD: Gleason 6 prostate cancer is a very common type. We grade these cancers on a 2-to-10 scale and 6 is right in the middle. He also has a nodule that can be felt on his rectal exam. His PSA, his screening PSA was 3.6 prior to this operation and he has had a CT scan, he's had a CT scan done to rule out metastatic disease, which was negative. 00:06:18 A. KARIM KADER, MD, PHD: So, you can see Dr. Hemal has now grasped the catheter and is pulling it up. Another assistant is going to be pulling down on the bladder and he'll start his posterior bladder neck dissection right here. 00:06:30

3 ASHOK K. HEMAL, MD: I cannot emphasize enough the role of assistant. Dr. Traver is doing an outstanding job, because this is team work, and I always say talented extraordinary people who help in this procedure, and I'm one of the members of the team performing this operation. So basically this procedure is a team procedure, and the patient-side surgeon or assistants, they're extremely important while doing this kind of procedure. What you can observe so far, what I have done, I have done division of the anterior bladder neck. You can see the wide bladder neck nicely and you can see here the prostate is lifted up. Dr. Jack is lifting the catheter up so the prostate is lifted up [in the stream]. And you can appreciate the bladder neck very well right over here. As I was telling you earlier, this prostate is a little wide, so you are seeing a large [unintelligible] on either side, but we will take care of that. So here is the bladder neck. And in short, we'll show you the trigone of the bladder, so we want to make sure -- we have to take care of the urethral opening. 00:07:40 JOSEPH A. PETTUS, MD: This is the part of the operation which is very important, because as he prepares the bladder neck, this the part of the bladder that will be then reattached to the urethra. And this is important in preserving continence that he not make too large or too small of a hole here in the bladder as he separates it off of the prostate gland. 00:08:08 ASHOK K. HEMAL, MD: Usually, back here as Dr. Pettus was this is really one of the very, very important aspects while doing this kind of procedure. And what we do usually, I lift the posterior part of the bladder neck. And I am trying to separate prostate away from the bladder, so that's the trick while you are doing this kind of step. And these are the layers of the [unintelligible] fascia. You can see the bladder is in my hand, and here you can appreciate the trigone right there. So what I'm trying to do, I'm trying to separate bladder off the prostate, because if I tried to go close to the prostate, I may enter into the prostate or I escape through the prostate. So I do want to avoid margin positivity, which is why I do not mind making a wide bladder neck, but I would not like to go to close to the prostate. Do you agree, Dr. Pettus? 00:09:00 A. KARIM KADER, MD, PHD: Yeah, I think both of us agree whole-heartedly. This is one of the most challenging parts of the procedure because, as you mentioned before, it's easy to get lost. Either go into the prostate or into the bladder. 00:09:13 ASHOK K. HEMAL, MD: So, you can see I made a quite wide bladder neck but I don't mind making a wide bladder neck because you can see the prostate is a little big. So because of that, the neck also will be bigger in comparison to that. So I have already gone through the couple of layers of [unintelligible] fascia. Can you give more perhaps lift this part? 00:09:40 A. KARIM KADER, MD, PHD: While we're continuing here, we'll just answer a quick question from our audience and remind everybody that they can ask questions directly to us by hitting the MDirect Access button on their screen. So, the question for you, Joe, is Why is robotic surgery more convenient than open surgery? 00:10:01

4 JOSEPH A. PETTUS, MD: Well, robotic surgery is not necessarily more convenient for the surgeon, but it is associated with a more rapid recovery time. Patients can expect to be in the hospital from between one to two days as they recuperate and also getting back to normal activity is substantially faster. So, convenient for the patient in that it's faster recovery and less pain, but this is the same operation as we do open. It's important to emphasize that the robot is simply a tool. The surgeon and his team are really the most important component of this endeavor. 00:10:45 A. KARIM KADER, MD, PHD: Okay, I -- 00:10:46 ASHOK K. HEMAL, MD: I would agree with Joe, what he said, because I am of an old generation. I was doing open radical prostatectomy, then I moved on to doing a laparoscopic radical prostatectomy. Now we are doing a robot-assisted laparoscopic radical prostatectomy. And as you see, you are seeing the magnified vision, and this vision is almost 10 to 15 times. And because you are seeing the magnified vision, and that's why you can see the structure very well, and you can delineate anatomy very well. As Dr. Pettus and Dr. Kader pointed out, if you know the anatomy very well and you can delineate it, you are likely to do a good operation. So, by and large, operation is the same as you do in the open surgery. Our goals are the same for our patient. We want to give him a cancer cure as much as possible, preserve continence, give him a potency, and these are the goals which you are trying to achieve. 00:11:41 A. KARIM KADER, MD, PHD: Great job, Ashok. Now, I just want to point out these Hem-o-lok clips for our viewers who aren't used to laparoscopic surgery. You can see that these are clips that we apply to achieve hemostasis, or get control of the blood vessels. They have a little hook on them. You can see that, at times, it's fairly difficult for that hook to lock, so there's a lot of technical aspects that go into the procedure that may not be appreciated by everyone. Why don't we cut to our rolling video and you can see all of the steps that have been done to get to this point. So, here you can see the initial view into the abdomen. Dr. Hemal has already placed the camera port and we'll be using that camera, introduced into the belly, to really look at the inside view while placing the assistant ports. Joe, where do you like to place your ports? 00:12:39 JOSEPH A. PETTUS, MD: I usually place my primary port just above the belly button and I'll place two additional ones about a hand's width away to each side and those will be my main robotic ports. Usually, we'll need to have two other ports so that the assistant can help in moving things around to show me exactly what I need to see to do the operation. 00:13:02 A. KARIM KADER, MD, PHD: You can see Bob Sandler here docking the robot, actually putting it into place. Michael Traver here is moving the robotic arms and is going to be fixing them to the robotic ports. You can tell the robotic ports because they do have a green rubber stopper on the end of them. Now, placing the ports is technically challenging, not placing them but positioning them, so that the robotic arms aren't interfering with one another. 00:13:32

5 JOSEPH A. PETTUS, MD: That's absolutely true, and if you don't place these ports just right, it makes the operation a great big struggle and again you cannot overemphasize the team approach to this because each individual effort really contributes to the overall result. 00:13:49 A. KARIM KADER, MD, PHD: Now you can see that Dr. Hemal is continuously wiping the end of his lens so as to avoid any fogging. This is the initial view into the abdomen. On his left-hand side, Dr. Hemal has a bipolar forcep, which is powered with PK, or plasmakinetic energy. Joe, do you have any preference with a PK versus standard bipolar? 00:14:13 JOSEPH A. PETTUS, MD: I really like it. I think that it cuts down on how much electricity is passed on to the surrounding tissues, very important when you're doing the nerve dissection, to avoid injury to those nerves for erections. 00:14:28 A. KARIM KADER, MD, PHD: Well, you can see here, the initial part of the procedure is actually mobilizing the colon on the left-hand side. This defines the anatomy and allows us to get the bowel out of the field. You can see a pulsating iliac artery in the distance there. Okay, so that's where we're at. Now, if we can cut really to the slide here outlining the steps of the procedure, we can look at the different steps involved in the robot-assisted laparoscopic prostatectomy. So really it's a general anesthetic positioning that we didn't go too much into before. Obtaining this new pneumoperitoneum or CO2 to inflate the belly so as to give us a good view of all of the structures inside. Trocar placement is then done, which you saw. Lysis of adhesions. Then we drop the bladder, so as to have access to the endopelvic fascia. We remove all the fatty tissue overlying the fascia. We take the endopelvic fascia, either with electrocautery or sharply, and then we take the dorsal venous complex. This is a complex of veins that can be quite problematic open. 00:15:38 JOSEPH A. PETTUS, MD: Yes, this is one of the primary advantages of the robot. When the belly is full of air, it decreases the amount of bleeding, particularly venous bleeding, and so the blood loss from robotic-assisted prostatectomy is considerably less than that seen in open surgery. 00:15:57 A. KARIM KADER, MD, PHD: So, if we go to our next slide here Actually, the slide that I have up, you can see how we take the dorsal venous complex, using the robot. This actually suture and then cut. Dr. Hemal was speeding through the procedure earlier and we didn't cut to him live before he got to this point, unfortunately. So, if we go on to the next slide here, you can see the anterior bladder neck dissection, which is where we really caught up to Dr. Hemal. Why don't we go back live to Dr. Hemal and see where he's at? 00:16:37 ASHOK K. HEMAL, MD: Yeah, what I have done, after cutting the posterior bladder neck, you see, you go to the seminal vesicle vas deferens complex, so you can appreciate that. There are the vas deferens and this is a part of the seminal vesicle. Jack, can you grab that? Mike, why don't you grab from the back side? That's good. And because there are a lot of vessels and we want to do a good enough division, so we are not using cautery

6 in that area, only when it is required. We try to use the minimum possible cautery. As you know, the nerves, they run close to the tip of the seminal vesicle, so we want to avoid using thermal energy in that area. Our goal is to give the best possible nerve division to our patient. And what I'm trying to do, I'm trying to dissect the seminal vesicle laterally, because most of the pelvic plexus, they can be close to the tip of seminal vesicles, so we are trying to dissect. And we do not believe in preserving the tip of seminal vesicles. Dr. Pettus might be, knowing there is a study by Peter Scardino and I think Eric Klein, Joe? 00:17:45 JOSEPH A. PETTUS, MD: That's right. 00:17:46 ASHOK K. HEMAL, MD: And in the study, they said if you preserve the tip of seminal vesicle, there can be more margin positivity, so we do not do that. All right, over to Dr. Kaden. Mike, you want to grab that? 00:17:58 A. KARIM KADER, MD, PHD: Okay, well we're going to field yet another question here from the audience. Joe, do you want to tackle this one? 00:18:06 JOSEPH A. PETTUS, MD: Sure, the question is, What type of robots are you using throughout this procedure? For this particular operation we are using the da Vinci threearm robot. Da Vinci is of course the main robot on the market these days. There are various types and the one that we're using is a three-armed robot. Here's another question from our audience. Karim, what are the security measures if the robot equipment fails? 00:18:40 A. KARIM KADER, MD, PHD: You know, it's rare. The quoted failure rate of the robot is about one percent, one to five percent. So, if by any chance that were to happen during a case, we're all trained open surgeons and we'd be more than comfortable completing the case in an open fashion. So, I think we're not exactly slaves to the technology. We have to stress that this is just one way to complete the operation and I think it's very important that you're well trained both open and robotically. 00:19:11 JOSEPH A. PETTUS, MD: It's also worth mentioning that this operation, before the robot came out, was done using laparoscopic only techniques and we've all been trained as well to do these cases and have done many of them and this can be achieved laparoscopically if it's purely a robot equipment issue. 00:19:32 A. KARIM KADER, MD, PHD: Now, why don't we cut to some slides on some basic statistics on prostate cancer? 00:19:40 ASHOK K. HEMAL, MD: First, I want to show you 00:19:43 A. KARIM KADER, MD, PHD: Why don't we cut back to the live footage? 00:19:44 ASHOK K. HEMAL, MD: Yeah, you can appreciate what we have done so far. Here you can see the bladder is lifted nicely and this is a rectum, which is a tented rectum. You can appreciate that rectum is tented. And these are the seminal vesicles attached to that. This is a [vesicle] prostatic pedicle on the left side. Can you appreciate that? So, this is the

7 [vesicle] prostatic pedicle on the left side, [vesicle] prostatic pedicle on the right side, and the bladder is up here. And the bladder is up here. That's the bladder opening. You can appreciate that, here is the bladder opening. So this is inside the bladder. This is behind the bladder. This is the right [vesicle] prostatic pedicle. Here is the left [vesicle] prostatic pedicle. And the seminal vesicles, they are lifted up. 00:20:24 A. KARIM KADER, MD, PHD: Now, Ashok? 00:20:26 ASHOK K. HEMAL, MD: Yes, Dr. Kader. 00:20:27 A. KARIM KADER, MD, PHD: We had a question here. Could you please identify the nerves? Will you be able to spare the nerves in this surgery? This is a good starting point right here. 00:20:36 ASHOK K. HEMAL, MD: Yes, that's a very, very good question. We are far away from the nerves. If you can appreciate that, the rectum is lifted up, so the nerves are right here, far below here. We're up high in this area, and you can see the prostate is here. So this is the lateral part of the prostate, and nerves, they run posteriolaterally here. We are far above the neurovascular bundle. You can appreciate that. This is the lateral part of the prostate. They should be somewhere there. 00:21:03 A. KARIM KADER, MD, PHD: So, what's really good is we have an idea of where they are now and at the completion of the case, we'll have a good appreciation of some railroad tracks, actually nerve-type structures, running on either side, where the prostate used to live. 00:21:21 JOSEPH A. PETTUS, MD: And, we'll be able to see that as the operation progresses here. Dr. Hemal is probably ten minutes or so away from starting to do the nerve dissection in this man. 00:21:35 A. KARIM KADER, MD, PHD: Now, why don't we cut away quickly to some prostate cancer statistics. In this first slide here, you can see that it's the most commonly diagnosed malignancy in men, with an estimated 220 thousand cases expected this year alone. Unfortunately, it's the second most common cause of cancer-related death in American men, with almost 26,000 cases expected. It's potentially curable when it's caught in its early stages. 00:22:04 JOSEPH A. PETTUS, MD: Now, fortunately in the modern times since PSA was introduced, the prostate cancer is most often detected at very early stages when it can be treated with surgery and be cured. But unfortunately for some, it just isn't caught early enough and that's what accounts for the large number of men who die each year. 00:22:27 A. KARIM KADER, MD, PHD: Yes, I think you bring up a good point. I think that there has been a tremendous stage migration where we've seen earlier disease that is potentially curable. Now, many people don't understand the anatomy of the prostate gland and where it lives and I just want to bring up a slide here to just demonstrate exactly where it is. So,

8 you can see the urinary bladder and the urethra and it's a structure that really lies between these two things. The nerves that supply the cavernosal bodies, or erectile tissue, of the penis are draped, literally draped, over the prostate, making the surgery very challenging. 00:23:05 JOSEPH A. PETTUS, MD: You can see here the prostate gland as it lives right underneath the bladder. It's right in front of the rectum, and that's what the doctor's feeling for when he does the rectal exam. You can actually feel the back side of the prostate gland. Fortunately, that's where most prostate cancers tend to occur. However, in a few cases, you will not be able to feel them and that is because the cancer will have occurred in another place. These are typically manifested by higher PSAs. 00:23:49 A. KARIM KADER, MD, PHD: So, yes, we advocate yearly screening in men over the age of 50 with a life expectancy greater than 10 years and you can see here that that screening involves a digital rectal examination and blood testing. Specifically looking for PSA, or prostate specific antigen. This is an enzyme that's normally produced by the prostate gland that's in an elevated levels in those people with prostate cancer. Here at Wake Forest we're actively developing new genetic tests to determine prostate cancer risk. Why don't we cut back to Dr. Hemal and his live surgery? I'd like again to remind everybody that they can push on the MDirect Access button on their screen to ask questions. 00:24:35 ASHOK K. HEMAL, MD: Right now, what I'm doing Dr. Kader, you can appreciate that this is a prostate here. I'm trying to go behind the prostate. And he has little adhesions in this area, so basically I'm very careful, because while I'm relieving the rectum out of the prostate, I don't want to get into the rectum. And this kind of [adhesions], they can happen post-biopsy. Now come here. As I'm moving along, I'm trying to go close to the apex of the prostate. So that's what I'm trying to do at this point in time. 00:25:04 A. KARIM KADER, MD, PHD: This brings up a good point. 00:25:06 ASHOK K. HEMAL, MD: My goal is to go up to the apex of the prostate posteriorly so that way the prostate is freed away from the rectum and going towards the apex of the prostate. So you can appreciate I'm trying to go as close to the apex, and I'm trying to do a dissection with blunt dissection and with the sutures. I don't want to use cautery in this area because I'm afraid I might not hit the rectum, so I have to be very, very careful. So you can see I'm [bleeding] this area. All right. 00:25:40 A. KARIM KADER, MD, PHD: Okay, Joe, how long do you like to wait between prostate biopsy and prostatectomy? 00:25:49 JOSEPH A. PETTUS, MD: Well, you know that's a really difficult question to answer and if you asked ten surgeons, you're likely to get ten different answers. I think that for most patients, a safe period of time is as few as two weeks, but I typically like to wait as long as about six weeks to let the inflammation from the biopsy settle down. 00:26:10

9 A. KARIM KADER, MD, PHD: I think this particular patient was well within that sixweek range. He's actually beyond that six-week range, and still despite that, there can be significant adhesions to the prostate. Now, fielding a question here from the crowd, What are the side effects after removing the prostate? Why don't we bring up this slide right here? The goals of prostate cancer treatment is what we call the trifecta: cancer control, first and foremost, but urinary function and sexual function are also primary in our minds. Really, those are the two major side effects from prostate cancer surgery. You can have loss of control of urine, which the rate is approximately five to ten percent who will experience that, and loss of sexual function, which if you go into the surgery with good sexual function, runs at about 50 to 60 percent. 00:27:12 JOSEPH A. PETTUS, MD: That's right and we've made constant advances in prostate surgery in terms of eliminating urinary problems and sexual function after surgery. This really started in the 1980s when we 00:27:29 A. KARIM KADER, MD, PHD: Why don't we cut back to the surgery while we continue this conversation? 00:27:32 ASHOK K. HEMAL, MD: What I'm trying to do now, I'm trying to go towards the right pedicle. You can appreciate what I have done so far. These are the both seminal vesicles on the right side and left side. Now we are planning to go to the right pedicle here. And we'll take care of the pedicle, then we'll go to the nerve division. Can you get me a Hemo-lok clip? I'm trying to avoid cautery in this area. I want to do as much as possible dissection with the cold sutures. The [vesicle] prostatic pedicle, it runs from the bladder towards the prostate. This is very important to control this pedicle before you move into this area. Can you get me another clip please? Now, here you can appreciate this is the lateral part of the prostate. It's to be far away from the nerves, which are located underneath that. Good, go ahead. Great. So now, why don't you grab this? I can't overemphasize how much help I'm getting with my assistants, Dr. Traver and Dr. Jacob Richard. They are doing an outstanding job. This is the area of the prostatic pedicle. There are two ways for the division. You can go in an antegrade manner or you can go in the prograde manner. This is still the area of pedicle, and you can see that. And I can come from here. There isn't one way of doing this. This is the lateral part of this, so I can open the prostatic fascia in this area and I can drop these nerves. So there are various ways of doing it. So I'll just try to show you two different way of doing a nerve division. 00:29:14 JOSEPH A. PETTUS, MD: It's important to note that he's just taken down what he called the pedicle. The pedicle is the medical term for the blood supply to the prostate. And this slides just in front of the nerve bundle, which he's now starting to separate off of the lateral, or side surface, of the prostate. 00:29:34 A. KARIM KADER, MD, PHD: This is a beautiful example actually, Joe. You can see the capsule of the prostate, which is deep there, and he's really doing a good job of peeling that tissue laterally off. That's going to be the nerves that are going to be important for erectile function, but there's a lot of data that suggests that they also help in continence. Do you believe that?

10 00:29:54 JOSEPH A. PETTUS, MD: I do. I think that even in men who have problems with erectile dysfunction that trying to spare the nerves is a worthy goal because it may help with continence. It's also important here to notice that he's not concerned about the blood loss that he's seeing. That's because here using electricity to stop the bleeding can actually damage the nerves, so it's actually better to go ahead and lose a little bit more blood just to spare more nerves. 00:30:26 A. KARIM KADER, MD, PHD: I think you know Pat Walsh, who is the grandfather of prostatic surgery, has a term for it. He spends a little bit of blood here, just in order to maximize that nerve function. 00:30:37 JOSEPH A. PETTUS, MD: But, again in robotic surgery, this blood loss for this part of surgery is considerably less than that we would see in open surgery because of the pneumoperitoneum, or the air that's inside of the abdomen, which serves to compress the blood vessels. 00:30:58 ASHOK K. HEMAL, MD: The nerves right here, they're running from here to here. Can you appreciate that? 00:31:01 A. KARIM KADER, MD, PHD: Beautiful example. 00:31:03 ASHOK K. HEMAL, MD: Actually, a lot of improvement in the nerve dissection is done by Dr. Menon from Henry Ford Hospital, which Bedois described these nerves posteriolaterally. And he described the preservation of the anterolateral fascia, which is also known as [unintelligible], and what he found is that some of the nerves there presented in the anterolateral fascia, so it's good to preserve it's appropriate to preserve that anterolateral fascia only in patients who have low-grade prostate cancer. So, let me once again show you this area, then you can go back to the slide. Here you can appreciate the big chunk of the nerves. So, nerves are far below that. Okay, so over to Dr. Kader. 00:31:51 A. KARIM KADER, MD, PHD: I think you know Dr. Hemal is doing an excellent job of showing us an antegrade approach to the nerve spare here. You can see antegrade refers to starting at the bladder and working away from the bladder, towards the urethra. He's using sharp dissection here and a bit of blunt dissection to just literally peel those nerves off the side of the prostate. By doing so, he'll avoid getting into the prostate and risk a positive margin, while preserving those nerves that are important for urinary and sexual function. 00:32:26 JOSEPH A. PETTUS, MD: It should be explained here that what is meant by a positive margin means that there is cancer cells that go up to the cut surface of the prostate and we try to have a small layer of normal tissue surrounding the prostate gland, because having cancer at the margin has been associated with recurrence. 00:32:50

11 A. KARIM KADER, MD, PHD: When we talk about recurrence, we usually talk about PSA recurrence. So typically after surgery, and really the benefit of surgery over radiation is that the PSA drops to zero. 00:33:03 JOSEPH A. PETTUS, MD: It does. It's definitive and it's easier to follow and decide when someone has actually failed then with radiation. But in all fairness, it should be pointed out that most patients who are prostate surgery candidates are also radiation therapy candidates. 00:33:21 A. KARIM KADER, MD, PHD: Definitely. There are different ways of treating prostate cancer. Now here, there's a question coming up. How much training in hours in procedures is necessary to be proficient in doing a robotic prostatectomy? That's a very good question and one that's being tackled right now at many different centers, including this one here. How do we train our trainees and how many cases or how many hours do they need to be proficient. This is really a field in evolution and we're getting better at training people doing it as we get better at doing the procedure. Now, you came from a big cancer center, Dr. Pettus. How did they tackle this problem? 00:34:11 JOSEPH A. PETTUS, MD: Well, in order to train residents or fellows, it's important that they actually have some consult time. This can be done in models or it can be done in live patients, but it is always done under strict supervision. As with all surgery, the more of it you do, the better you become, and as with all surgery it is very individual as to what a particular surgeon has in terms of natural ability as well as experience. But I think that in general in order to be truly proficient with it, that a minimum 20 cases to be as good as you are going to get. Probably hundreds of cases. There are probably very few people who do this kind of operation who could not still see improvement above and beyond that which we see today. 00:35:06 ASHOK K. HEMAL, MD: Yeah, I would agree with Dr. Pettus because a robot is just a tool, so basically it depends on the surgeon's experience and while doing a cancer surgery it's very, very important to excise cancer completely. That is the primary goal while doing this kind of procedure. You don't want to compromise anything. So, I guess what Dr. Kader was alluding to, the point you may want to grab here, Mike. When you are doing a robotic procedure, usually people say, the training, you may want to do 50 cases before you get onto the things. Even in the recently held meeting, people who were talking to become completely proficient in doing this procedure, it may take up to 200 cases, you know. So, it depends in every case, like as we say, there is no tailor-made treatment for the cancer prostate for every patient. You have to decide according to the tumor of the patient, his lifestyle, and what kind of disease he has, what kind of cancer he has. There are so many factors involved while treating this kind of disease. So therefore, it is very, very important and you have to tailor, really, according to the patient's need. And basically, it also depends a lot about what kind of cancer he has, how much involvement he had, how many [costs] are involved. Over to Dr. Kader. 00:36:30 A. KARIM KADER, MD, PHD: You can see here that Dr. Hemal is starting to preserve the left-sided nerves and he's just finishing off the last bit of the left-sided vascular

12 pedicle, those structures that give the blood supply to the prostate. Now, I think in this patient here Dr. Hemal has done part of the lymph node dissection and plans on completing it. What do you use, Doctor? 00:36:59 ASHOK K. HEMAL, MD: Basically, this guy, there was one reading, his PSA was 29, so we got his CT scan done. You may want to come back and hold that. We got CT scan done, bone scan done, and both were negatives. And usually, what we do when there is we do all four subsets of the lymph nodes. I like taking the obturator group of the lymph node, iliacus group of the lymph node, [unintelligible] lymph node, and also the external iliac vessels. That's what I typically do, but not as radical as one would like for the cancer of the bladder. 00:37:36 JOSEPH A. PETTUS, MD: I think that the lymph node dissection is very important as a cancer operation. I think that it is more complete. It adds valuable information about what you can expect in the future from your cancer, but it also may have some benefit to about one in five patients who has very small microscopic nodal metastases. So I think that it's a very important adjunct to this procedure, also in patients who have negative lymph nodes, it's possible that they had a very small part of the lymph node that was positive and that surgery was actually curative of that and I think that those data are starting to emerge. 00:38:25 ASHOK K. HEMAL, MD: Yeah, I would agree with Dr. Pettus. Usually I do -- in all of my cases, by and large, I do a lymph node dissection. And it doesn't take much time. My patient here, all three of us, we get different cases, and most of the patients they give us, we do do a lymph node. You will do a lymph node in my case, I just showed. You know, we don't want to leave anything in doubt, and we don't mind doing a lymph node. It doesn't take time. And the other thing, what Dr. Kader and Dr. Pettus was talking about the training thing. Because our training centers, and we have our residents and fellows, so what we do, typically we keep two assistants, like when they're [at level], there are three. So one of the assistants can be on the left side and one can be on the right side. That way we do our assisting the procedure all throughout this, then you are paying a lot more attention than you are watching on the video. That way you know with left-side assistant, after doing five or ten procedures he becomes proficient to go on the right side, and the right side assistant is ready to go to the console. Now you can see beautifully how nicely you can appreciate the nerves here, Dr. Kader and Dr. Pettus. See this is a nerve, so you can see very well on the left side. 00:39:38 A. KARIM KADER, MD, PHD: Well, why don't we cut to that internal view? 00:39:42 ASHOK K. HEMAL, MD: Oh, you are not seeing the internal view? Oh, I am so sorry. 00:39:45 A. KARIM KADER, MD, PHD: Now we've got it. Okay, perfect. 00:39:48 ASHOK K. HEMAL, MD: So this is -- so you can appreciate the nerves on the left side. I have dissected all anterioposteriorly, and this is that. Let me show you. You can see the prostate. You can grab that, Mike. So this is the left side of the prostate, and you can see I

13 have dissected all this posterolateral part, and now I'm trying to move towards the apex, you know. 00:40:13 A. KARIM KADER, MD, PHD: So, this particular patient, Ashok, has a very interesting bit of anatomy here. In a small subset of patients, they can have what we call an accessory pudendal artery. 00:40:24 ASHOK K. HEMAL, MD: Yeah, I preserved the accessory pudendal artery in this case. He had a bilateral accessory pudendal artery. And I think you might recall the paper published in the Hoffman's by Dr. Badois' group, and it said that 10 to 15 percent of people can have accessory obturator artery. And if you preserve the accessory obturator artery, that helps in early recovery of sexual function. And we do not [jab], we always preserve the accessory obutrator artery as much as possible. Do you agree with me? 00:41:02 A. KARIM KADER, MD, PHD: Yes, exactly. I couldn't agree with you more. And I think that the robot affords you the opportunity to visualize that accessory artery. 00:41:10 ASHOK K. HEMAL, MD: I feel with the robot, the main advantage I'm feeling, I'm seeing the magnified vision. And like in these kind of angles, having my laparoscopic instrument that I have been a straight laparoscopic radical prostatectomy, so I know, you know, after doing one case at the most, you can do two, not more than that, then you get tired. Here with the wristed instruments, you can go to any angle, you can do whatever you can do. That is the advantage of the robotic instrument. And you are seeing the three-dimensional view as you would see in the open surgery, so a visual advantage. So, vision, magnification, and three-dimensional view with the endowristed movement. You can see the seven degrees of movement. Now I am ready to go to the urethra. Back to you, Dr. Kader. 00:41:57 A. KARIM KADER, MD, PHD: Well, Dr. Hemal is making some great time here. He's almost got the prostate completely dissected out. We've only got about 20 minutes left. Why don't we cut to some questions. While nerves can be spared, to what degree are they traumatized from the procedure? Joe, do you want to tackle that? 00:42:15 JOSEPH A. PETTUS, MD: Sure. Well, that's a great question. In fact, they are traumatized to some extent as they're being peeled off of the prostate gland, but they do recover albeit slower than we might like for them to. Typically we'll see the return to potency anywhere from just a month out from surgery to as far out as two years after surgery. This is very dependant on the individual man. We do know that men who are younger do tend to have better and faster recovery of both sexual function and of their urinary control. Another viewer had asked us how much time will elapse after surgery for the incontinence to disappear and return of bladder comes. Dr. Kader, would you like to address that? 00:43:05 A. KARIM KADER, MD, PHD: Well, that's another excellent question, and again, that's very variable. It can be as short as six weeks, as long as 18 months. I think the degree of return of function happens quicker earlier on in the recovery period and slower as the

14 patient continues to recover. There is anecdotal data to suggest that there may be some earlier return to continence in using the robotic prostatectomy. Again, that's anecdotal and that remains to be seen. 00:43:37 JOSEPH A. PETTUS, MD: Now, this part that Dr. Hemal is about to perform is absolutely crucial to return of continence. You want to spare as much of the urethra as you possibly can. The urethra is the tubular structure that he has on stretch there. The more urethra you can preserve, the more likely you are to have return of continence but this has to be balance by the desire to control the cancer because the reason we're here is to get rid of the cancer and we try at the same time to preserve continence. 00:44:14 ASHOK K. HEMAL, MD: If you appreciate what I have done, I have lifted the suture. This is a sphincter urethra complex I have lifted up, and you see the prostate is here. And this much complexity is sphincter urethra complex, so you can go underneath the dorsal venous complex and you can go to the apex of the prostate. And that is the advantage. You get a good length of urethra you can get this way. We got good control of the dorsal venous complex. So far at least it's not bleeding. We'll see now how does it do. Back to you, Joe. 00:44:48 A. KARIM KADER, MD, PHD: So, I think Dr. Hemal has made an excellent point with respect to his dorsal venous sutures here. He's really pexied up that dorsal venous complex to the pubic bone. There is data to suggest that this may assist in continence. What do you think, Joe, Dr. Pettus? 00:45:10 JOSEPH A. PETTUS, MD: I agree with everything you just said. Again, this portion of the procedure is absolutely crucial to this man's future continence. 00:45:22 A. KARIM KADER, MD, PHD: As well, if you look at most published series, the highest margin rates are in this area. Really, you can see beautifully here in this dissection where the prostate is, where the urethra is, and really try to maximize cancer control while at the same time preserve urinary function. 00:45:39 ASHOK K. HEMAL, MD: You can see the prostate here. That's the apex of the prostate, and this is the urethra here. And you don't want to jeopardize the nerves, which also run lateral to the apex of the prostate. So you can see this fascia going to that area. This side, if we divide that so I'm trying to peel that off. Now you can see the urethra nicely in the vision. Can you appreciate that? 00:46:08 A. KARIM KADER, MD, PHD: Yeah, we've got a very nice view of that. Now, Dr. Hemal is going to be trying to come underneath the urethra and is going to be taking the anterior aspect of the urethra. That's what's being done now. Now, you can see the catheter? 00:46:20 JOSEPH A. PETTUS, MD: The top of the urethra, that's right. He just pulled the catheter back and now he has his left arm underneath the urethra. 00:46:30

15 A. KARIM KADER, MD, PHD: Now, prostates come in all different sizes and shapes. This is potentially one of the reasons for a positive margin. 00:46:40 ASHOK K. HEMAL, MD: Now you can see, I cut that urethra, but the prostate is going here, so I have to take care of this part also. 00:46:45 A. KARIM KADER, MD, PHD: So, these are muscle fibers directly posterior to the prostate that attach the rectum really to the prostate, so it's another area where you have to be very careful, know your anatomy well and really have good visualization. The last blow of the prostatectomy was right there. 00:47:08 ASHOK K. HEMAL, MD: All right, so we are done with the prostate. Into that bag, please. 00:47:12 A. KARIM KADER, MD, PHD: So now we put the prostate in a bag. Dr. Hemal will continue on and finish a node dissection. We will dissect any significant areas of bleeding, which there don't seem to be any on this particular case. 00:47:33 JOSEPH A. PETTUS, MD: As we're doing this, we could get to a couple of other questions from our viewers. One question, Dr. Kader, In high-grade disease, how do you decide whether or not dissect the nerve bundles or whether to spare them without the ability to directly feel the prostate gland for nodules? 00:47:55 A. KARIM KADER, MD, PHD: I think that's an excellent question and there are different tricks we can use in cases with high-grade disease to see whether or not that disease really approaches the neurovascular bundles. One is endorectal coil MRI. Endorectal coil MRI can give us some idea as to where the cancer is and if it's a small focus of cancer and if it's centrally located, we may still opt to spare nerves on that side. On the other hand, though, if there does seem to be involvement of the neurovascular bundle or at least disease approaching that, we will resect the neurovascular bundle on that side and try our best to spare the bundle on the contralateral or other side. 00:48:39 JOSEPH A. PETTUS, MD: As with open surgery, I think that the ability to be able to feel for nodularity in the prostate gland 00:48:48 A. KARIM KADER, MD, PHD: Why don't we just cut to the node dissection here? He's just finishing off a left-side lymph node dissection. 00:48:54 ASHOK K. HEMAL, MD: Yeah, what I'm trying to do here, you can appreciate these are the obturator vessels. Here are the obturator vein, obturator artery, and this is the obturator nerve. So I'm trying to take out this pack. All right, can you bring it down, please? See, there is a small bleeder here. So usually, we take out the external iliac group of the lymph node. You can appreciate the external iliac vein. This is the external iliac vein. Here is the obturator nerve. This is the obturator artery, and here are the obturator vein. And this is the iliacus muscle. So these are the areas one would like to clear when you are doing lymph node. Can you pull toward the pelvis side?

16 00:49:39 JOSEPH A. PETTUS, MD: This is a very nice lymph node dissection. It's done almost exactly the way we would do it open. The anatomical boundaries of the lymph node dissection are the same, only with better visualization than you can have open. In open surgery this is down in a deep hole. Here you can zoom in with the camera and you can really see things considerably more up close than you can with the open procedure. 00:50:09 ASHOK K. HEMAL, MD: All right, I am ready for the anastomosis suture, please, and meanwhile Dr. Kader, you can take any questions that you have. 00:50:14 A. KARIM KADER, MD, PHD: Okay, after you take out the prostate, what will you use to connect the bladder with the urethra of the penis? Well, you're going to see that right now. We'll be using absorbable suture, a suture that will dissolve. It does take a fair length of time for it to dissolve. Another question, which was related to this, was the importance of the Foley catheter. I cannot stress the importance of the Foley catheter enough. To allow that connection between the urethra and bladder to heal over time is critical. Finally, what are the expected levels of PSA concentration right after the procedure. Joe, Dr. Pettus? 00:50:53 JOSEPH A. PETTUS, MD: Well, right after surgery, the PSA will decline over time. But even just two weeks out after surgery, we expect for the PSA to go to what we call undetectable, and that's usually in most labs these days a Occasionally you can take slightly longer than two weeks to go down to undetectable, but typically we'll expect it to be there by two weeks and that's what we'll expect it to be for the rest of a man's life. We'll monitor it for going up and if it goes up it will make us worry that there has been a recurrence. 00:51:28 A. KARIM KADER, MD, PHD: Now, you can see here the anastomosis, or connection between the urethra and bladder, is continuing. You can see that Dr. Hemal has just passed the needle from inside of the urethra to the outside and is now going from outside the bladder to inside the bladder. These sutures here are going to be key to brining everything together the way it was before the surgery. 00:51:55 JOSEPH A. PETTUS, MD: When we were doing this using purely laparoscopic techniques, this was one of the parts of the operation that was very, very difficult. One of the things that the robot brings to this operation is that it really allows you to use your hands as you would use them during open surgery. It allows you to have, we call it wristed motions, that is, it's as if you have a wrist. It's not just two-dimensional motions in the way that you do with laparoscopic surgery. 00:52:27 A. KARIM KADER, MD, PHD: So, you can see that wristed motion in action right now. Dr. Hemal's hands are within two finger holds. He's actually turning his wrists and those movements are being transmitted inside the body under really precise control. It's truly microscopic surgery that happens under very precise control. Wouldn't you agree, Dr. Pettus? 00:52:50

17 JOSEPH A. PETTUS, MD: I would agree, and in fact you can actually change the control of the hand so that larger movements are transmitted as very smaller movements, making extremely fine surgery possible. 00:53:07 A. KARIM KADER, MD, PHD: So it will control for any potential tremor that may exist. Now, you can see that Dr. Hemal is completing the posterior, or back side of the connection. And really, there's no denying that this is going to be a very solid type of connection. 00:53:25 JOSEPH A. PETTUS, MD: It should be pointed out also that this one difference between open surgery and robotic surgery. Open surgery is interrupted, or rather we use stitches through the urethra and the bladder neck. Here he's actually using a running suture so that there aren't gaps between the stitches. 00:53:46 ASHOK K. HEMAL, MD: Actually, we started using, when I was working with Dr. Menon, we used to do first interrupted sutures, then we went on to the hemi-circle, and then we really started doing continuous suture. And part of the credit goes to the [unintelligible], which described the continuous suture anastomosis for the laparoscopic radical prostatectomy. We modified that suture and we tried to do this way. This gives you a watertight anastomosis, and you can take out depending on the other factors, like how are the local disease, how are the things, and you can take out catheter in three days to one week to two weeks, depending on the situation. So I think -- and you can see how nicely urethral sphincter complex is preserved and you can see I have suspended. So now I'm done with the posterior and the left part. Now I'm going to start on the right side. I'm trying to hold the needle there so I can give some correction. 00:54:47 A. KARIM KADER, MD, PHD: So you can see that he used two stitches that were actually tied together. And he just finished the back end of the anastomosis and the lefthand side of the anastomosis with a blue stitch, and he's going to continue on for the right side and the top of the connection with the tan stitch. And this just keeps him from making a mistake, grabbing the wrong stitch. So, another question from our audience, Will robots be doing most of the surgeries several years from now? 00:55:18 ASHOK K. HEMAL, MD: Well, I can tell you the history. I was very fortunate. [Mr. John Whitcomb], he was the first man in England in the [Guide] Hospital. He did the first [field] robotic procedure in In true sense, when you see a pure robotic surgery, it should be totally automatic surgery performed by the robot. There's no human assistance like as you do in the car factories or manufacturing units, or so on and so forth. But here you see the robot is a slave for us. Basically it is like surgeons who are performing surgery. So I think we are far away from that arena when the robot will be doing the surgery at this point in time at least, I guess. 00:56:02 A. KARIM KADER, MD, PHD: No, I think you're right. That really stresses the point that this is a robot-assisted laparoscopic prostatectomy, not a robotic prostatectomy. 00:56:12 ASHOK K. HEMAL, MD: Correct. Can you bring suction, Mike?