Surgeon: Ashutosh Tewari

Moderator: Clint Bahler

Discussants: James Peabody and Rosalia Viterbo


 

Webinar Transcript

Dr. Clint Bahler:

Okay. We want to welcome everybody to the first of our 2021 robotic endo urological master class. We have a special treat today and that the president of the society of urologic robotic surgeons, Ash Tewari is joining us. We also want to acknowledge the support that intuitive surgical has given, which makes this event possible. So today's session is on the robotic prostatectomy. We're very excited to have Dr. Tiwari with us. We also have two discussants. So Dr. Rosalio Viterbo, Fox chase cancer center renowned for their work in cancer. Also Dr. Dr. James Peabody from the Vattikuti Institute. Which has a long history of pioneering in robotic surgery. Dr. Ash Tewari is the chairman of the Mount Sinai healthcare system and, of course, is well known for his research and surgical advances in the robotic prostatectomy.

Dr. Clint Bahler:

This events is CME accredited and look for an email to come to you with instructions on how to claim that credit. So the conflict of interest are also listed on the endo urological website. The format for today's webinar, we're going to have a presentation by Dr. Tiwari on the robotic radical prostatectomy. During that time, please use the chat function to leave your comments and questions, and our discussants during that time, we'll answer those questions that will also form the basis for the last 20 minutes of question and answer.

Dr. Clint Bahler:

CME can be received, just follow the instructions on an email that will come from Michelle Paoli. We also want to invite everybody to join us on a new program. This is masterclass spotlight series. This will go live in March of this year. It's going to be held the following Wednesday after a Friday masterclass, and it gives you an opportunity to join a community for commentary and discussion and sharing your own surgical videos and techniques. Finally, we wish to invite everybody to join the endo urological society as a member, and also to join us in the 2021 real Congress of endo urological meeting, which is in Germany. So without further ado, we'd like to turn it over to Dr. Tiwari for his presentation.

Dr. Ashutosh Tiwari:

Thanks a lot Clint, and thanks Jim. In our first robotic masterclass, we will be having 12 of them this year. It's my true honor to be president of the society of endo urological robotic surgeons. I will try to do everything possible to expand this program, expand the society and make bridges across the continent. Coming onto the topic today. My presentation today, we'll be talking at a hood approach of performing robotic radical prostatectomy. We recently published that as in surgery, in motion for European urology. Basically by approach is inspired, by the work done by the Regis sparing surgeon, Dr. [Bachadi 00:03:51].

Dr. Ashutosh Tiwari:

This is the recent paper which came out. The key word here is we are trying to spare the structures which are important for continents and are located in the space of Retzius, makes it very easy to perform, makes it very easy to adopt, and it has an impact on the early return of continents. It allows you to manage the ontological factors easily.

Dr. Ashutosh Tiwari:

This was taught through in our mind by some of the figures, which I drew. Got into the details of the anatomy, had an artist that draw them in a more professional way. We looked at potential advantages and we thought that the median lobe, and sometimes it's small numbing of the BPH and the ureteric orifices, can be seen with this approach. It can be done transperitoneal or extra peritoneal. I haven't been performed at trans vesical. We are not working in a small space. All sides prostates could be handled. Possibilities spare the bladder neck, or reconstruct based on the ontological and the anatomical factors. We can spare the critical structures, the critical structures in the pouch of Douglas, just like we do it in a normal radical prostatectomy. We can change the planes. We can do the grades of node sparing.

Dr. Ashutosh Tiwari:

Most of the robotic surgeons are used to have this approach. We were interested in saving the interior structures in the space of Retzius early on, and this is a paper from 2008 or something. It was led by my colleague, Dr. Takenaka from Japan. These are the pictures from the recent publication. What we are trying to save looks like a hood, and that is the reason we are calling it as a hood technique. We have looked into the anatomy on a sagittal view of an MRI on the left side. This is what we are trying to save. Then trans rectal ultrasound and in good quality, we can see the structures which we are trying to save. This picture shows exactly what we are saving. This is an annotation on top of an MRI showing body structures. We are saving.

Dr. Ashutosh Tiwari:

This is a postoperative MRI on inpatient in which after hood technique, we are seeing what exactly has been saved. As I mentioned, it can easily be applied to and median lobe. I will be showing you more videos. This is a big median lobe, but the more important it can be applied to a small numbing, often sub trigonal BPH tissue, which can produce a PSL later on and produce a lot of anxiety. With that background, I will present with the data that at four week, about 50-60% of the patients are totally continent. As you can see, I have super impose my own data from past. That is the blue line and the red line. It's showing that how soon the continence comes. I'm not seeing it on the day of the catheter removal. I'm seeing it at about four weeks to six weeks. You get a very good continence.

Dr. Ashutosh Tiwari:

With this background, I'm going to show you a video. That video is going to highlight the key components of it. The first component is to get some space and I'm not going to spend too much of a time on that. So what I'm doing here is to retract the ligaments left and right. I'll put in a clip here. Same thing will be done on both the sides. I will develop a plane like a tunnel. So the first part of this approach is that making a tunnel without disrupting too many structures, close to the pubic bone. I'm getting close to the prostate vesicle junction.

Dr. Ashutosh Tiwari:

I have dissected enough to find the prostate vesicle junction here.

Dr. Ashutosh Tiwari:

Now I'm trying to find the bladder neck. In this patient, at least I knew that he didn't have a big prostate or a big median lobe, so I tried to save the bladder neck, make it smaller. But I can make an adjustment and make a bigger bladder neck without any problem. As mentioned before, in my presentations and publications, the posterior part of the bladder neck leads us to a layer of tissue, which we call retro trigonal layer. That retro trigonal layer is the one which I will demonstrate here. It is hiding the seminal vesicles and Vas. It connects from... So underneath this is the Vas Deferens.

Dr. Ashutosh Tiwari:

So we have not opened the endopelvic fascia. We have not exposed the pubic bone. We have just found the front of the bladder, and I'm trying to demonstrate the retro trigonal layer.

Dr. Rosalia Viterbo:

Dr. Tiwari, where is your progress currently? Is it holding-

Dr. Ashutosh Tiwari:

It is holding the Foley catheter upwards.

Dr. Ashutosh Tiwari:

So I will get to a plane. Identify the front of the Vas and some of the vesicle. March a little laterally, as much as I need to without getting too close to the neurovascular tissue, which we are very far at this point.

Dr. James Peabody:

Are you trying to just get to the latter edge of the VAs deferens here?

Dr. Ashutosh Tiwari:

Yeah, I mean, I think at the end of it, that entire lateral tilt thing needs to kind of move away from us. So I'm trying to make the least amount of window without using cautery. I want to deliver the Vas in front of me, which is happening as we talk. I'm trying to be cognizant of not overusing the cautery.

Dr. Ashutosh Tiwari:

Now it looks like that I have at least one of the Vas in my hand. This Vas will lead me to the tip of the seminal vesicle. You're seeing it on a real time. I can fast track it, but I want to continue a little slowly here.

Dr. Rosalia Viterbo:

Your exposure it looks very nice. Is your assistant helping a lot or is it just a nice-

Dr. Ashutosh Tiwari:

He has been with me for last a minute 1000 cases. So this guy knows more about it than anyone else. I used the thing I'm very good at assisting, he is much better. Dr. Peabody will remember my assistant's days.

Dr. James Peabody:

You were very good, Dr. Tiwari. That's how you learn how to do the operation by watching it in the beginning. That's how we all did it.

Dr. Ashutosh Tiwari:

So my key here is that I will deliver the Vas Deferens as anatomically as we can. Once we have the Vas exposed, then I will explore what I call medial avascular planes of seminal vesicles, because that will lead me to the tip of the seminal vesicle as we'll get to that.

Dr. Rosalia Viterbo:

You're dissecting planes appear very nicely. Have you encountered cases where the dissection doesn't go as smoothly and it's a little more difficult to-

Dr. Ashutosh Tiwari:

Usually in life cases. No, but you're right. I think, if you have someone who had seminal vesiculitis, or sometimes people who have had procedures through lasers, or some kind of an envisioned, there was some urinary extract. They become difficult. Then you go back to the fundamentals, you start to developing planes little bluntly and see the things. So this is what my pro grasper was doing, and now it is coming down to hold the two Vas Deferens. And once I have the Vas Deferens in my control, I will develop the medial avascular plane here.

Dr. James Peabody:

This is a nice technique to hold the two of them up so you can get access to that-[crosstalk 00:14:11]

Dr. Ashutosh Tiwari:

I think if you hold one, I usually break them. Because it gives me a little bit more strength by having two of them together.

Dr. James Peabody:

That's a great, great trick. This was one of the nicest planes of the whole dissection I think when you get-

Dr. Ashutosh Tiwari:

Dr Peabody, you have not mentioned one of the disclosures. You were my residency director. You are supposed to say all good things so let everyone know that.

Dr. James Peabody:

I'm not sure who taught who more.

Dr. Ashutosh Tiwari:

But this is the medial vascular plane I'm getting into. So I'm slowly trying to get as far as I can with the tip of the seminal vesicle.

Dr. Rosalia Viterbo:

This is where a good assistant is really helpful. Putting enough traction where you can see, but not too much so that the tissues [inaudible 00:15:15] in, during your dissection planes.

Dr. Ashutosh Tiwari:

I'm so proud of Jeff. He is amazing.

Dr. Ashutosh Tiwari:

I mean, as Jim and I used to talk about it, this is one operation. We have to be neurosurgeon, cancer surgeon and a reconstructive surgeon, all of that. So little slowness here, and there is not a bad idea. You should take your time.

Dr. James Peabody:

You want to get here, to the point where you've isolated the vascular pedicle. So you can get a clip on it. Is that?

Dr. Ashutosh Tiwari:

I'm getting to the clip. I'm not seeing the tip yet. So this is the small vertical, which I think I can easily cut it, buzz it, but the chip is there. So I think will you get it to me. Once I get this one up, then I will get a little bit the other vertical.

Dr. Rosalia Viterbo:

So do you use a combination of bipolar clip and maybe even some monopolar energy to isolate some of these vessels?

Dr. Ashutosh Tiwari:

I mean, I think if it's a smaller [inaudible 00:16:53], you can just touch and go. That kind of a thing. If the clip is likely to damage more than the instrument, like I just did it, if I could.

Dr. Ashutosh Tiwari:

I'm almost touching the seminal vesicle right now.

Dr. Rosalia Viterbo:

It's a nice plane.

Dr. Ashutosh Tiwari:

So right now it is ready to be swabbed and my scissors will help me and I will hold... Now I'll develop the plane on the opposite side.

Dr. Ashutosh Tiwari:

This is one of the superficial vessels I should just buzz it, maybe I'll do a clip. I don't recall. But... You saw he tried to get the second one also. I couldn't show it to him very well, but we still...

Dr. James Peabody:

He's holding your retro trigonal layer there. Right?

Dr. Ashutosh Tiwari:

That's right. The retro trigonal layer becomes a good tissue to hold and grip. Then I think his suction is going to be key. He'll put the suction in that lane. Sometimes that opens up things for you.

Dr. Ashutosh Tiwari:

We hear the decent side speed tip. So I'm just spending my time.

Dr. James Peabody:

Dr. Tiwari you may remember Dr. [Valencien's 00:19:09] quote, that sometimes to go fast you have to go slow.

Dr. Ashutosh Tiwari:

That's right. I mean, I think that's true in life also.

Dr. James Peabody:

Take good care here.

Dr. Ashutosh Tiwari:

Then the tip kind of... It is a slow process, but it gets done.

Dr. James Peabody:

Ash, there's a question. If you had clip migration into the anastomosis using clips here to-

Dr. Ashutosh Tiwari:

So I think most of us, who do a lot of these, know that the clip migration is not a user clip, but if we were anastomosis. I don't think it happens anymore.

Dr. James Peabody:

Yeah. I think you're right about that. A good anastomosis will be resistant to any clip in the neighborhood.

Dr. Ashutosh Tiwari:

It used to happen before. I mean, I think, but for the last couple of years, no.

Dr. Rosalia Viterbo:

Ash, do you tend to use a variety of clip sizes or do you usually stick to one size and-

Dr. Ashutosh Tiwari:

Both five and 10 millimeter is my favorite. Five [inaudible 00:20:49] is not that reliable, but sometimes if I've shown the vertical very well then... By the way, sometimes poor clip response is not the clippers problem, but the fact that I'm not showing it good enough. So now I think both sides are done. Now, this is the time when I'm getting into midline in a plane which is posterior to the capsule. I have a philosophy, there are no nerves in the midline. So I'm going from midline plane as deep as I can, and [inaudible 00:21:28] march laterally.

Dr. Ashutosh Tiwari:

Understanding layer within the layer, I think is important. Even my team members, they kind of understand which layer I want to be. We have already made it pre-surgical decision as to which plane I want to be. Sometimes identifying a perforator and getting rid of that perforator is important so that we get into the right planes. As we have talked before, I am becoming more and more focused on the distal part of this dissection. What I call the harness. There is in harness of nerve (Wilders and Hamad), but there's an harness of nerve which goes more distally and converges in the ethical part. So as much of a time we can spend under vision sharply, bluntly, thermally, automatically will help-

Dr. James Peabody:

Switch to 30 up sometimes when you're doing this.

Dr. Ashutosh Tiwari:

I do that sometimes. I think I've been focusing on just this. So this is the important part which we used to call it, the triangle. There is a neurovascular triangle at the base where nerves are entering into it, facial compartment. Getting into that triangle is in very important part of our rest of the dissection. I also will not be shy of sometimes cutting it sharply and let it bleed a little bit here. If I cannot get a good clip, because getting into that plane is very important. I'm trying to get into that plane. Once I have that plane ready. This is the vein, which is attached, and I'm trying to develop a plane. There is a small bleeder here. That's all it needed. So I am pretty good posteriorly, but I will finish this part a little bit more on division.

Dr. James Peabody:

So what do you think of the concept that your nurse bearing has really started and set up for success by your posterior dissection.

Dr. Ashutosh Tiwari:

I think you're right. That determines the plane. If you are in the right plane, then you can march laterally a little bit and slowly you will get to the right area. But the particular is where it kind of can confuse us in getting into the right plane. So getting into that triangle is also important. I think we are getting into a decent triangle, and now I will change the position. That is the key.

Dr. Ashutosh Tiwari:

So far I was pulling it Midline. I will change it. So I will start retracting it more towards the contralateral side. This is what the hood is. You can see all the structure that we have saved before. I have separated prostate from posterior lateral aspect and I'm more [inaudible 00:25:06] here. Since there are no nerves in this area, I will be a little liberal in using cautery because this is the area where I've already disconnected it from the prostate. So this is the hood, which is being developed right now. As I have shown in that MRI, and then the histopathology, it starts from inside anterior fibromuscular stroma, which should always be on specimen capsule, which should always be on a specimen. But then there is the plane which involves the tissue, which involves the muscle fibers and collagen fiber vein. Finally, the diffuser apron and sometimes ligaments and all those things. So that is what I'm trying to get into it.

Dr. Rosalia Viterbo:

I think it's key to develop that plane at the median sulcus and then creep up. I think it allows you to hunk the prosthetic capsule and save all that tissue, which I think is key for this[crosstalk 00:26:01],

Dr. Ashutosh Tiwari:

You are right. That is the reason, since I do an MRI before surgery, I'm kind of pretty sure that there is no issues with the anterior fibromuscular stroma. This is the same plane we get into when we are doing the rigid squaring approach. Instead of that we are coming from the side. So for me, the left side of the hood is done and it looks like a hood, that's the reason we call it the hood.

Dr. Rosalia Viterbo:

This technique I'm sure allows you to visualize in the areas that may have been missed on an MRI. So as you're creeping up from a space, that's pretty clean in the median sulcus. If you move laterally, if you saw some suspicious tissue, I would think you could change your grade of nerve sparing as well.

Dr. Ashutosh Tiwari:

You are absolutely right. We used to call it, reverse braille. Meaning, if people can read by just the touch, we can feel just by an exquisite vision. After doing X number of cases, you start seeing structures that doesn't look right, and if in doubt, you just kind of make an adjustment and go a little lateral. We call it, invisible cues during the robotic prostatectomy and I think most of us who do a lot of these cases, they know that this issue doesn't look right phenomena. We can make an adjustment right on the spot.

Dr. Rosalia Viterbo:

Many times if I see suspicious tissue, I will send some to pathology for a frozen. Do you ever do that Dr. Tiwari?

Dr. Ashutosh Tiwari:

Yes, we do.

Dr. James Peabody:

Ash, there's a question about your positive margin rate at the apex. I know we can talk about that, some in the discussion. You may have some more slides about that too.

Dr. Ashutosh Tiwari:

My total positive margin rate is around 10 to 12%, which include everything. Since I am very selected in which patient I will do this technique, we have a margin rates not going up more than what I used to have it before.

Dr. James Peabody:

I know you'd said that people have an anterior biopsy or a lesion anteriorly on the MRI, you'll be more reluctant to do this technique. Is that-

Dr. Ashutosh Tiwari:

So in the first couple of hundred, yes. But now this is what I call you can modify it. You can have a hood on one side and then partial hood on the other side. Once you know that you're getting close to the area where they can't say you leave a little extra tissue on the specimen. So I shouldn't say that. That should be the first set of patients to be getting it done. Ideal answer is, if with an anterior tumor do something else.

Dr. James Peabody:

Yeah. You have pretty exquisite view of the tissues here with this. So you, as Lia was saying, you can make an adjustment pretty readily if you encounter something that doesn't look right.

Dr. Rosalia Viterbo:

Would you do this technique on a patient who didn't have an MRI? Who couldn't get an MRI or maybe even an exact ultrasound?

Dr. Ashutosh Tiwari:

Couple of months ago, no. But unless and until I have done a targeted biopsy of that year part. Of late, I've been very happy with the exact view. So if the exact view is negative. I will take an extra tissue biopsy, but ideally we should be sure that we are not dealing with it until it's [inaudible 00:29:35].

Dr. James Peabody:

Ash, a lot of people have proceeded through to just get to the apex and complete the prostatectomy before putting into our Sylvan stitch. I assume you're doing this because it gives you a more bloodless field and maybe some better [crosstalk 00:29:54].

Dr. Ashutosh Tiwari:

I mean, I think for demonstration, whether I use this or not, the bleeding is hardly any. I want people to appreciate that what plane are we doing it. Otherwise, I'll be just fast track it to get to get to that point.

Dr. James Peabody:

Okay. And this suspension stitch gives you maybe some help with continence and maybe some better exposure. What's your thought on that?

Dr. Ashutosh Tiwari:

I don't know.

Dr. James Peabody:

Okay.

Dr. Rosalia Viterbo:

Do you always use a suspension stitch Dr. Tiwari?

Dr. Ashutosh Tiwari:

Of late, yes.

Dr. Ashutosh Tiwari:

Apex is where I think we need to spend some time, think it through. As you can see, we are not exposed people. Prostetic ligaments are not going close to any one of those structures.

Dr. Rosalia Viterbo:

There's a question from the chat, whether you would use this technique for a known anterior tumor?

Dr. Ashutosh Tiwari:

No. If someone tells me that there is an anterior tumor on the right base, yeah. I will use it. I will make a distill partial hood kind of thing. But if it is right at the apex, it's in the midline, not a good idea. I use this suture. I think this is an important suture before disconnecting everything I will put in a stitch, which goes through the urethra, goes through the [inaudible 00:31:33]. This suture will prevent me from needing perineal pressures and all kinds of things, which we used to have.

Dr. James Peabody:

This is a barbed suture and you'll[crosstalk 00:31:48] use it for your anastomosis?

Dr. Ashutosh Tiwari:

Yeah.

Dr. Rosalia Viterbo:

It's a nice technique to really give you a nice bite of the urethra before it retracts.

Dr. Ashutosh Tiwari:

So right now the specimen will be sent. I do want to kind of jump onto the next level.

Dr. James Peabody:

That suture's an old city of hope move.

Dr. Ashutosh Tiwari:

Yeah. So now I'm doing a reconstruction of the posterior side. Specimen is gone, is being re-read. I'm trying to find the Vas, not important at all, but I'm doing it. I want to close the [inaudible 00:32:54] if I can. So this is the retro trigonal layer again, being reconnected.

Dr. Ashutosh Tiwari:

If I have to say that my approach has three very much Italian inspiration. One is a [Rocco 00:33:22] inspiration. Second is in Bachadi inspiration and third is the [Pagano 00:33:26] inspiration. Meaning, this is a modified palm up in Rockwell test, which I just did. It saves the instructor in the Retzius space as highlighted by Dr. Bachadi. I will do a little bit of [inaudible 00:33:43] here, a wrap kind of thing. That is the Dr. Pagano. So all combined, this is basically a sum total of what I have learned from my Italian colleagues.

Dr. James Peabody:

Ash you had the balloon blowing up on the catheter for a little bit, and that also camping odds a little bit oozing that may be coming from the period refill tissue makes it easier to see, which is also a nice trick, I think.

Dr. Ashutosh Tiwari:

Yeah. I mean, I think it is, um, it is one of the methods in which you can minimize some of the bleeding and don't need too much of cautery later on. So it [inaudible 00:34:18] it for a few minutes and then it gets relatively dry.

Dr. James Peabody:

Yeah. Sometimes that's all you need.

Dr. Ashutosh Tiwari:

So right now I'm going to bring it a little bit posture so that the people know that I will take about six more stitches. Ultimately it will look like this.

Dr. Rosalia Viterbo:

What size suture are you using right now? It looks like[crosstalk 00:34:46].

Dr. Ashutosh Tiwari:

I think it's in two O.[inaudible 00:34:48]

Dr. James Peabody:

It looks like two O. [crosstalk 00:34:53]

Dr. Ashutosh Tiwari:

first time using a three O.

Dr. James Peabody:

Okay. You'll try to get this down to about 20-22 French, something like that.

Dr. Ashutosh Tiwari:

20 French. Then I will put in an 18 Prince catheter. How are we doing with the time?

Dr. James Peabody:

We have a 23 minutes left.

Dr. Ashutosh Tiwari:

Okay. This is a good way to watch it.

Dr. James Peabody:

So when you're doing a full thickness bite here, and then do you kind of run it back down or?

Dr. Ashutosh Tiwari:

Yeah. So I will go back, with the same suture for a second layer. That is what the Pagano's thing, is that wraps it up for you.

Dr. James Peabody:

It also moves the ureter orifice as well, out of your way for your hands to [inaudible 00:35:46].

Dr. Ashutosh Tiwari:

If you visualize that Jim, it kind of gives you extra length of the urethra. I mean, so ureteric orifices are now a couple of inches behind. So this one will be reflected downwards. Then when it goes downward, that means you gain this multiple length of the urethra. Visualize it, this urethra, I would have been made in anastomosis from the distal part, but now this anterior part will be getting connected to the urethra. This part.

Dr. Rosalia Viterbo:

What if you had a smaller bladder neck, would you still do that?

Dr. Ashutosh Tiwari:

Then I be will not reconstruct.

Dr. Rosalia Viterbo:

But this certainly helps you where you don't need any extra perennial pressure. It looks like you have a nice day.

Dr. Ashutosh Tiwari:

I think the extra perineal pressure used to be a major issue. Also sometimes when an assistant is giving him perineal pressure and also moving the catheter in and out, false passages can form. So this has taken away that anxiety and with the robot there, it's not easy to get the real pressure. So this suture kind of helps me in getting to the...

Dr. Rosalia Viterbo:

Definitely gives you the control to be able to adjust the pole.

Dr. Ashutosh Tiwari:

After it is [inaudible 00:37:18] down then I will pause track and we can have more questions if we need to. Or?

Dr. Rosalia Viterbo:

There is a question from the chat. If you get any patients with postoperative perennial pain after this type of posterior reconstruction?

Dr. Ashutosh Tiwari:

So perineal pain discussion happens if I have to put in a stitch very distantly near the [inaudible 00:37:40]. You saw that I delivered, we didn't put in there. The perineal pain can happen if there is a, what you call, seminars modic leakage lapses and all those things. So one thing that's in major concern. One of the most thing which I'm working on it is in some irritation or sometimes a stricture because of the catheter. So that is something which we are trying to figure it out.

Dr. Ashutosh Tiwari:

When this thing goes down, you can basically glide then as much as down. First thing to make sure that you're not holding it yourself. I was doing it.

Dr. Rosalia Viterbo:

This is coming together very nicely Ash. Do you ever see any super continence after this?

Dr. Ashutosh Tiwari:

They used to call it hyper continence. So I think every, maybe one or 2% of the patients may need an extra catheter per day for a few days, but nothing will be more.

Dr. James Peabody:

You have your assistant move the catheter back and forth to make sure you didn't catch the catheter there.

Dr. Ashutosh Tiwari:

That's correct. The key is that he should tell that I got the catheter when I'm holding the needle in my hand. I can pull it back at the same time. Even though it looks very easy thing, this is what my team does most. This part of the job, they don't like it. Because I'm the one who's getting the catheter and they are the ones supposed to protect it.

Dr. Rosalia Viterbo:

Looks like you have a nice flow going with your assistant.

Dr. James Peabody:

You put a little product back there, posteriorly. Can you just talk about your philosophy on doing that, when you do it, or?

Dr. Ashutosh Tiwari:

I think, I instead of using Bovie to buzz small bleeders, if I can control it with that, sometimes I will use a flap of fat also to reduce the dead space. So this is, [inaudible 00:40:14]cell, which is an absorbable thing. I don't want that[inaudible 00:40:21] tumor.

Dr. Rosalia Viterbo:

Ash. There's another question. Do you change your port placement to do a hood technique or do you use the same port placement?

Dr. Ashutosh Tiwari:

I don't think port placement has changed much. No. I mean, I think with the excite robots, I don't think we need to change the [inaudible 00:40:43]. What do you guys think?

Dr. Rosalia Viterbo:

Agreed.

Dr. James Peabody:

I don't think you probably need to make any adjustment.

Dr. Ashutosh Tiwari:

When I did the single port, then the port placement is different. I have done it, but I don't do that for you right now.

Dr. James Peabody:

Did you find any problems using this technique with the single port? The few cases you did.

Dr. Ashutosh Tiwari:

Not part of the technique, but it looks clumsy for-

Dr. James Peabody:

Yeah, that's been our experience too. But we're learning to love it.

Dr. Rosalia Viterbo:

There's another question. Does doing the pelvic lymph node dissection gives you any challenges when using this techniques or [crosstalk 00:41:45]

Dr. Ashutosh Tiwari:

We can easily expand the exposure. The key word is, it's not just the tunnel, it's what I did with the brunt of the prostate. That can still be done and I can open up the tissue proximally to do a good lymph node dissection. Sometimes we have closed that area also, after doing the lymph node. So there is no hernia, but you can do the same lymph nodes. If it is a limited lymph node, you can make a lateral sneaky plane, between this plane and, the external iliac vein. If you have to really do a good nodes in an extended manner, then I think you should open up at proximally and then decide whether you want to close it or leave it open.

Dr. Ashutosh Tiwari:

So at the end of it, it looks a little bit like this. This isn't an old case. It's one of the recent cases from last two weeks or three weeks. There are more cases there. I want to show.

Dr. Rosalia Viterbo:

It's very nice anastomosis.

Dr. James Peabody:

So Ash, if you were to do a lift out dissection here, would you try to stay inside of the umbilical arteries?

Dr. Ashutosh Tiwari:

No, I mean, I think if you really have to do a good lymph node, then you have to get [inaudible 00:43:42].

Dr. James Peabody:

So you come back out and I know you said that you've been closing that anterior flap of stuff to repair the analyze things. Is that a regular part of the practice or occasionally? Or how do you decide to do that?

Dr. Ashutosh Tiwari:

Say it again, one more time.

Dr. James Peabody:

You've been closing the anterior part of the flap that you take down for the tunnel. You've been repaired to [inaudible 00:44:03] the retro to the Retzius space. Sometimes.

Dr. Ashutosh Tiwari:

I think I use it only when there is a no lymph node dissection discussion and all those things. Otherwise, can you see it now?

Dr. Rosalia Viterbo:

Yes.

Dr. Ashutosh Tiwari:

So basically the key components of... And I can show you some of the key points here more. I can focus on nerve-sparing one more time in here. So that is the key. This is what I call that the hood is being put together. This is another video in which I'm just doing the hood part of the discussion.

Dr. Rosalia Viterbo:

The nice part about this technique is that you can probably do a hundred percent nurse bearing on the one side and on a side that you're suspicious. You can really easily adjust your technique.

Dr. Ashutosh Tiwari:

Yes you're right. You can tailor the operation. What I call it is an early release. If there is a concern on one of the sides, I will open up that area. This is in one case in which you can see a lump there, you can see a lump, but I have seen that it was not visible on an MRI or on an ECE discussion. So this is another case in which I had to reconstruct and then how it looks like afterwards.

Dr. Ashutosh Tiwari:

So this is what the key figure is that at the end of it, when I'm done, this is what I save. So this is one patient who had a PSA recurrence that allowed me to get a postoperative MRI. Post-operative MRI and the X-Men scan and all those things didn't show something in the pelvic area, but I got a chance to look at the anatomy.

Dr. Ashutosh Tiwari:

So this is what you are seeing. This is how, what I have saved. This entire structures are saved. This is partly the urethra and all those things. This is about continence. Any other questions or parts?

Dr. Ashutosh Tiwari:

My summary is, it is inspired by three different technical innovations. It includes principles of saving structures in the Retzius space. It doesn't save the space, but it does save the structures. I can be versatile in removing it on one side or making more wider dissection on one side. You saw it in a real time. It is possible to do a good nerve sparing. It is possible to look at the ureteric artifices. It's possible to manage median lobe without any problem. It is very rewarding to be comfortable that you didn't leave a dubbing of BPH tissue in the trigon, which will later on produce PSA.

Dr. Ashutosh Tiwari:

I can change the grades of nerve sparing based on what I'm seeing. I would leave the podium to Jim and Rosalie to kind of comment, summarize whatever questions you have.

Dr. James Peabody:

Good. There were a couple of other questions that came up. Some of this, I think you touched on, but maybe a little bit more, cause there were some questions after you'd made the comments, but about the apex, MRI positive near the apex, there's a tumor in the anterior stroma. Can you just sort of review again for the audience what your thoughts are about that? How you approach that? I think there's still a couple of questions.

Dr. Ashutosh Tiwari:

So if there is a tumor at the anterior apex, if there is a tumor in the anterior part in the stroma, don't go into this plane. You have to open up the endopelvic fascia, definitely on the side where the tumor is more dominant. You have to go beyond the edge of the prostate and slowly march backwards. This is not a procedure for everything and you shouldn't be doing it.

Dr. Rosalia Viterbo:

Dr. Tiwari, you showed a very nicely how this technique can help you in patients who have a small median lobe or even a large median lobe. What about in patients who've had prior surgeries? One of the panels is asking, like a prior TURP or maybe a patient who's had multiple TRPs. Could you use this technique or would you use something else?

Dr. Ashutosh Tiwari:

No, I mean, I think anything at the bladder side, the bladder neck side is not a problem we can handle it. It's mainly I'm concerned about if something anteriorly is an issue. I mean, you can see this is in same tech road being done on a median lobe.

Dr. Rosalia Viterbo:

What about a patient who had a TURP in the past? Would you do a cystoscopy first before deciding on this technique? Or would you just go ahead and do it?

Dr. Ashutosh Tiwari:

I mean, I think if I'm concerned about contracture, if I'm concerned about big median lobe, then I will consider doing a cystoscopy. Otherwise, I think since it adds continence, and those are the patients who are more likely to be in continence. So I would rather do this than not do this.

Dr. Rosalia Viterbo:

Makes sense. Does the hood technique take you additional time or do you find it the same time?

Dr. Ashutosh Tiwari:

I think initially everything new will take time and I'm slow anyway, but I do three every day. You saw almost in a real time the surgery, I mean, I think. So this is how the median lobe part is being tackled. And the-

Dr. Rosalia Viterbo:

Another question is what was your learning curve like? How long did it take you to feel comfortable with this? One of the panelist is asking.

Dr. Ashutosh Tiwari:

I think maybe 10-15 cases.

Dr. Rosalia Viterbo:

What was the biggest challenge as you got started?

Dr. Ashutosh Tiwari:

It's still, we are used to working in a much more wider space. So exposure is the key, big surgeons make big incisions discussion we come from that generation. Understanding what we need from that space is the key. Sometimes you have to work with your hands like this rather than lateral. If you don't have a good assistant, your blood pressure may go up a little bit.

Dr. James Peabody:

So worthwhile rehearsing this with your assistant before you do the first case?

Dr. Ashutosh Tiwari:

Yeah, I think... Then see the videos. I think these videos and all those things are very available.

Dr. Rosalia Viterbo:

I always find it very helpful to go over any videos with my assistants so that they know what I expect and they know what's needed as far as exposure.

Dr. Ashutosh Tiwari:

I will actually ask both Jim and Rosalie, what am I not focusing on? What can we think about improvising or you think I should be thinking in a different way?

Dr. James Peabody:

How can you make this technique better is what you're saying?

Dr. Ashutosh Tiwari:

Better and reproducible and easy for others to adopt. I mean, this is the hood, what you're seeing right now.

Dr. James Peabody:

These are all steps that people who do robotic surgery are familiar with. There's nothing here. There's no technical aspect. That's different. You just to put it together in a very nice way. A lot of time, 20 years thinking about how to do this operation. This distills down some of the principles that doing things there thermally trying to preserve the structures as much as possible. I think there's still some debate about why exactly [inaudible 00:52:51] sparing procedure is better in terms of continence. It may be what you're just showing there, the truce or apron that you're leaving more undisturbed. It's an interesting topic.

Dr. James Peabody:

One of the audience members wrote that they think that the continence is more related to the subtract gonial suspension and wondered what your thoughts were about that. I guess that may be as opposed to the interior suspension or reconstruction work that you were doing there. Can you kind of talk about your philosophy there ish?

Dr. Ashutosh Tiwari:

So I kind of will look at the facts, which I'm absolutely sure about. Patients at least 98% of them are totally continent before I did the surgery. Something is working all right in them before that two hours, one hour, about the surgical time. So all those instructors are intact and the patient is continent. I also know when I do and very extensive radical post salvage kind of surgery, patients are more likely to be incontinent.

Dr. Ashutosh Tiwari:

So something is in between, and in my own journey, I have... Then third facts, I think Retzius sparing does give an early continence. So I think in any hand, Retzius sparing is giving better continence than everything else which was there before that. These three facts are there. So Retzius sparing is a) Keeping the structures intact. B) Saving the structures in front a little bit and less dissection of the blood and neck, all things are happening. So instead of taking one thing at a time, I am just adding in one thing at a time and seeing if the continence is getting better. I can still say that on the day of catheter removal, Retzius pairing will have a better continence than what I just showed you. But four weeks later, it doesn't matter. If I get a benefit, of kind of been more precise and nerve sparing, more precise and by grades of nerve sparing, my cancer control discussions, my reconstruction and easy adaptability, I want to continue using the steps which I was using.

Dr. Ashutosh Tiwari:

So posterior reconstruction has a role to play and that's the reason I said, this is a triple Italian technique: Pagano, Rocco, and Bachadi, all combined into Dr. [Walsh's 00:55:30] and Dr. [Mann 00:55:30] and synthesis of how to do this thing. I can easily take away certain part of it. I do know when the more radical dissection patients take longer time to put the continence. Not nerve-sparing, wider dissection, anterior apical tumor, salvage setting, and patients with[inaudible 00:55:53] active syndrome. Patients who had QR before. Patients who had even HIFU and all those things, they are more likely to lead. Patients who were a little older, also were more likely to lead. I used to think that the bigger prostate had the same problem, not anymore. I think bigger prostate, I'm not finding that bad it is. Meaning continence data. So any one of these components may contribute. I don't know, but definitely anterior part is getting an earlier continence. I'm not saying it is getting an ultimate better continence.

Dr. Rosalia Viterbo:

I think you can either reconstruct the anterior apex or like you did, preserve all the structures. I think you showed very nicely how that is key to early return of continence. Very nice.

Dr. James Peabody:

Potency has been pretty good.

Dr. Rosalia Viterbo:

It's not changed. I mean, I think it depends on the grades of nerve sparing. If I can have be hugging the prosthetic capsule, they have a much better chance. If they are good to start with, if I am between a grade two, that is outside the Venus plane, then I lose about 10-15% of sexual function. If I am at a grade three, which is an incremental, I lose another 10-15%. Grade four is about when I'm not really doing any nerve sparing and then the data is not that good. So yeah.

Dr. James Peabody:

Thank you, Dr. Tiwari.