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