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Dr. Shaw has spent more than a decade refining his DaVinci Robotic Prostatectomy technique, beginning in 2000 at the Tulane Urology Program in New Orleans, where he was part of the first robotics program in the Gulf Coast area. From there, he was one of the first robotic surgeons in Austin, Texas, pioneering several firsts in the area including the first robotic cystectomy (bladder removal). He also traveled throughout the United States training other urologists in this new technology, as well as attending conferences to share best practices with thought leaders in advanced robotics.
Dr. Shaw’s highly evolved robotic prostatectomy has reduced surgical times to two hours in most cases and the vast majority of his patients are in the hospital for 24 hours or fewer. Studies show that reduced operative time and shorter hospital stays can lead to lower complications and faster recovery.
The DaVinci Robotic system utilizes HD optics and 3 robotic arms, each no wider in dimension and not much longer than a ball-point pen. Using these small incisions, the robotic arms replicate Dr. Shaw’s movements in a surgeon console about three feet away from the patient.
The benefits of a robotic prostatectomy include smaller incisions that often lead to less pain, HD optics with 10-15x magnification that allow for less blood loss and precise incisions that assist with delicate nerve-sparing and dissection that help to optimize outcomes of continence and potency after the surgery, while also maintaining adequate margins around the prostate to ensure that we give the patient the best chance to be free of prostate cancer.
Once the patient is safely induced under general anesthesia, we make five small incisions, each no wider than a dime. One incision is at the umbilicus, or belly button, for placement of the HD camera optical system. Eventually this same incision is slightly widened to remove the prostate. Two additional incisions are placed on either side of the umbilicus, three of which are used by the DaVinci Robotic system, and one by our bedside assistant to place sutures, etc.
A unique approach that Dr. Shaw uses is the “posterior dissection technique.” We identify the posterior peritoneal covering the vas deferens and seminal vesicles. Once identified, we transect the vas deferens and dissect out the seminal vesicles. We use minimal cautery (heat) in this dissection, as use of excess heat can potentially injure nerves that are important for preservation of erectile function. We also dissect as much as possible posteriorly, developing a plane between the prostate and rectum.
We then turn to the anterior aspect of the dissection, where the fibro-fatty tissue above the bladder is taken down with spot use of cautery. Once this is completed, the bladder neck and anterior aspect of the prostate is exposed completely.
We then make precise incisions into the endopelvic fascia on either side of the prostate. This exposes the levator musculature that forms the muscular complex surrounding the base of the bladder, bladder neck, and urethra, a critical component of maintaining urinary continence. No electrocautery is used as we perform this dissection bluntly to expose the lateral and apical aspects of the prostate.
Following exposure of the prostate along its anterior, lateral and apical surfaces, we proceed with ligation of the dorsal venous complex or DVC using a 0-V-Lock suture at both the apex and mid prostate. Placing these sutures markedly reduces blood loss and facilitates adequate visual planes and also exposes the lateral aspects of the prostate to facilitate neurovascular sparing when appropriate, to help with preservation of postoperative urinary continence and potency. I have also found that this assists me in identifying the correct plane between the bladder and prostate and preserving the bladder neck size, which also helps with restoration of postoperative urinary continence. Once the sutures have been placed, the lateral aspects of the prostate are well-visualized. Depending on preoperative biopsy mapping and MRI studies, we perform nerve sparing as indicated. Incisions are started at the mid prostate, and carried towards the base and apex from there. The apical neurovascular sparing is completed once the apex of the prostate is transected later in the case.
After both neurovascular bundles have been spared to the apex, I follow the neurovascular bundles to the base of the prostate. This guides me to the prostatico-vesical junction bilaterally. I mark these areas with cautery at both the left and right aspects of the prostate. Once this is completed, I score a line using cautery between the demarcated left and right sides of the prostatico-vesical and begin dissecting in the center, until the anterior aspect of the urethra and foley catheter are exposed. The balloon in the foley catheter is taken down and lifted up anteriorly, exposing the junction between the prostate and bladder neck. Thereafter, the prostatico-vesical junction dissection is completed in an anterior–>posterior plane until the seminal vesicles and bilateral vas deferens are encountered, both having been dissected as step one of the procedure. Both seminal vesical and vas deferens are then lifted up anteriorly, exposing the lateral prostatic vascular pedicles. The vascular pedicles are in close proximity to the nerve plexus that is critical to preservation of postoperative erectile function. Weck clips are used to clamp the vascular pedicles, and cautery is used sparingly, if it all.
Once the lateral prostatic pedicles are taken down, the neurovascular dissection is completed bilaterally from base to apex, with no utilization of cautery to ensure the greatest chance of preserving postoperative urinary continence and potency.
After neurovascular sparing is completed as indicated, the apex of the prostate is transected with cold scissors, again without use of cautery to enhance preservation of the urethral sphincter and neurovascular complex, which come within millimeters of the prostatic apex. Urethral preservation, to make sure the maximum length of urethra along with distance to the urethral sphincter is performed as dictated by presence or absence of cancer in the apex of the prostate. Following this, I have found that reconstruction of the posterior urethral plate and recto-urethralis musculature has greatly enhanced postoperative urinary continence recovery, with our patients being 90%+ continent within six weeks after the procedure, with almost all our patients achieving full continence within 12 weeks. A 2-0 V-Lock suture is utilized to bring the posterior bladder neck, Denonviller’s facia, and rectourethralis musculature together and recreate a “posterior-urethral plate.” This bring the bladder neck and urethra together within close proximity as an added benefit, allowing us to perform a urethro-vesical anastomosis in a tension-free manner. Once this is completed, the bladder neck and urethra are re-anastomosed with a running 2-0 Quill PDS suture, with double arms. The integrity of the anastomosis is tested by filling and emptying the bladder twice with 120cc saline. Pelvic lymph node dissection is then completed as indicated by the prostate biopsy pathology and preoperative PSA.
The prostate is then placed into a entrapment device that is brought out through a small widening of the umbilical port site incision. The incision is closed with a combination of vicryl, monocryl, and skin glue. All other port sites are closed with a combination of monocryl and skin glue.
After spending about one hour in the recovery room, our patients go to a dedicated Urology Postoperative Recovery Floor, where all nurses are highly trained in our protocol. Clear diet is had for lunch/dinner with bedrest recommended initially postoperatively. Sequential compression devices are used postoperatively to reduce the chance of DVTs, or deep-vein thrombosis after surgery, and an incentive spirometer is also used to encourage deep breathing and ventilation postoperatively. Most of our patients are given a powerful NSAID, Toradol IV, a cousin of Ibuprofen. With this protocol, a large number of our patients find pain control adequate the point that narcotics are not necessary, which reduces nausea, constipation, and grogginess that impedes early ambulation postoperatively.
The morning after surgery, most of our patients enjoy a regular diet and begin walking with assistance on the surgical floor. By lunchtime, 75% of our patients are ready to go home on oral pain medications and can shower the following day. The remaining 25% of our patients may need a second day in the hospital depending on their needs.
Seven to ten days postoperatively, our patients return to our clinic to have their foley catheter removed, and to review pathology. They immediately start Kegels exercises, to regain urinary continence, as well as start daily Cialis, which studies have shown to help stimulate the neurovascular complex and speed return of erectile function postoperatively.
We then follow up with our patients six weeks postoperatively to re-assess potency and continence. Our patients are approximately 90% dry by week six, most wearing a small liner. By 12 weeks, the majority of our patients are completely dry. At the six week visit, we also check an ultrasensitive PSA, which we benchmark to 0.008 as being clinically undetectable. We then follow the PSA, as well as continence, and potency every six months for two years, and yearly thereafter in perpetuity.
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