Surgeons: Ashutosh Tewari and Richard Gaston

Moderators: Bernard Rocco and Thomas Ahlering


Dr. Ashutosh Tewari is the Professor and System Chair of the Milton and Carroll Petrie Department of Urology at the Icahn School of Medicine at Mount Sinai, an integral component of the Mount Sinai Health System which includes seven New York Hospitals. He also serves as a member of the Tisch Cancer Institute and Institute of Immunology at Mount Sinai. Before coming to Mount Sinai Dr. Tewari was Director of the Lefrak Center for Robotic Surgery at the New York Presbyterian Hospital/Weil Cornell Medical Center, and was Ronald P Lynch Professor of Urologic Oncology in the Department of Urology Center and Professor of Public Health at Weill Cornell Medical. Dr. Tewari was the founding director of the Center for Prostate Cancer at New York Presbyterian Hospital/Weil Cornell Medical Center.
Since 2013, the Department of Urology has undergone significant expansion under the leadership and vision of Dr. Tewari, and today it provides state-of-the-art services for the diagnosis, treatment, prevention, and management of a wide variety of urologic conditions, including genitourinary cancers. Among his other significant achievements are the recruitment of basic scientists, surgeon-scientists in the areas of kidney cancer, bladder cancer, kidney stones, endourology, and the recruitment of new medical directors for Interventional Urology, Focal Therapy program and Men’s Health programs.
Dr. Tewari has been a pioneer in Robotic Surgery and has been involved in the development of Robotic Prostatectomy from its inception. He has made a major impact on the anatomical foundations as they apply to Robotic platforms and has performed over xxxx robotic prostatectomies in his career. He is a clinician scientist who has incorporated the use of molecular diagnostic tools like Onctotype Dx, Decipher, Prolaris, Precision medicine, Sema-4 and FoundationOne for risk stratification and decision support.

Dr. Tewari has made seminal contributions to prostate cancer research. Over the past several years Dr. Tewari has studied various aspects of prostate cancer including surgical prostate anatomy, genetic risk profiling, epidemiology, racial disparities, risk modeling and survivorship issues. Dr. Tewari leads a multidisciplinary team of basic and clinician scientists with key focus on immunotherapy clinical trials, studies on racial disparity of cancer, radio-genomics and functional genomics of tumors; inter and intra-tumor heterogeneity, drug resistance, tumor-microenvironment and immune adaptation, epigenetics, viral vectors for gene therapy, neo-antigen and biomarker discovery platforms for GU cancers. He has also contributed to the understanding of MRI based imaging and racial disparities in prostate cancer.

Richard Gaston is the Head of the Department of Urology at Saint Augustin Hospital, Bordeaux since 1985. In 1991 he started with laparascopic surgery and in 1997, he performed the first radical prostatectomy in Europe. Richard Gaston is active member of various urological societies and on the editorial board of a variety of international journals.


Prof. Bernardo Rocco was born in Milan, 31 October 1973. Graduated in 1998 (110/119 cum laude) at the University of Milan, Italy. He post graduated in Urology in 2003 (70/70 cum laude) and registered to the state medical board of Milan, Italy and Switzerland. In 2009 he attended a one-year research and clinical fellowship in Robotic Surgery at Global Robotics Institute, Celebration (FL).
From 2003 to 2011 we worked as Medical Assistant at the Department of Urology at Istituto Europeo di Oncologia, Milan; during 2009-2011 he was Deputy Director and Director of Surgical Robotic School at the same Institution. From 2011 to November 2016 he worked as First Level Medical Executive at Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan. On November 2016 he became Associate Professor in Urology at the University of Modena e Reggio Emilia and First Level Medical Executive at Nuovo Ospedale Civile Sant' Agostino Estense di Baggiovara, Modena, Italy.
Since November 2018 he is the Chief of the Department of Urology at the University of Modena, Italy, and Full Professor in Urology at the same Institution.
He is a mentor in robotic surgery – in both adults and pediatrics - at national and international urological units and performed several live cases of robotic procedures; he is a co-inventor of the posterior reconstruction technique (Rocco’s stitch) and promoter of its use during minimally invasive radical prostatectomy.
He is Author of more than 190 articles indexed in Scopus and Pubmed, accounting for an overall H-index of 29 and more than 3600 citations.

Dr. Thomas Ahlering is a highly regarded surgeon in Urologic cancers, with years of experience in treatment of prostate, bladder, kidney and testicular cancers. He did his residency and a two-year fellowship in urologic oncology under Dr. Donald Skinner at the University of Southern California. His research concentrates on maximizing functional recovery through patient-reported outcomes following RARP. He has collaborated in pioneering new treatment modalities and principles such as the van Velthoven urethrovesical anastomosis, reducing NVB traction injury, multi-center trial on an online email patient portal, etc. He has multiple investigator-initiated trials on continence and sexual function, including the predictive capability of 30-day continence and 90-day percent fullness on long-term patient outcomes. Further, his publications have established that delay of recovery of sexual function is best explained by well-established Neurosurgical principles of peripheral nerve injury and recovery. In one of his RCTs he strongly demonstrated that surgeon skill and not inflammatory-based surgical injury is far more responsible for more complete and faster potency preservation and recovery. Thus, robotic prostatectomy produces improved outcomes for the patient in reduced blood loss, nearly zero blood transfusions, low complication rates, earlier return to work, and excellent oncological outcomes with low positive margin rates.

 

Webinar Transcript

Dr. Chandru Sundaram:

Hello. I'm delighted to welcome you all to our second Robotics Surgery webinar. On behalf of the Endourological Society and Dr. Adrian Joyce the chair of the Office of Education I welcome you to this webinar.

Dr. Chandru Sundaram:

Every two weeks until the end of this year we will be having world class leaders host webinars in various aspects of robotic surgery. It is my pleasure to introduce to you the President of the Society of Urologic Robotic Surgeons Dr. Jihad Kaouk. Dr. Kauok.

Dr. Jihad Kauok:

Thank you Dr. Sundaram. Again, we're very excited to present to you the second session of our webinar series presented by the Society of Urologic Robotic Surgeons (SURS) and the endourology. Today we have a very exciting program with leaders in robotic prostate surgery from all over the world.

Dr. Jihad Kauok:

Today, two surgeons will be presenting their outstanding techniques in robotic radical prostatectomy. We will have Dr. Dr. Ashotsh Tewari, who is very well known in the field of prostate cancer, the Chairman of Urology in Mt. Sinai Hospital in New York. And also, I am delighted to introduce Dr. Richard Gaston, who is the Chief of Urology in St. Augustine Hospital in Bordeaux in France, who have taught us a lot of the elegant techniques in robotic prostate surgery. And you will watch 20 minutes of his surgery.

Dr. Jihad Kauok:

We are joined by moderators. From Italy we have Dr. Dr. Bernardo Rocco who is the Chief of Urology in Modena, Italy, and Dr. Tom Ahlering who is the Chief of Oncology in UC Irvine and a very well-regarded surgeon in prostate cancer among other urological oncologists. And also, I am delighted to have Dr. Bo Yang who is a robotic and laparoscopic surgeon in Shanghai Urology Department in China, a department that's a very well-known leader in minimal invasive surgery under the chairmanship of Dr. Ying Ho Zhong. Thank you all for joining us today.

Dr. Jihad Kauok:

I want to mention that this seminar is being supported by an educational grant by Intuitive. We have ... This session will make you earn a CME credit of one credit for each seminar that we are going to be doing by monthly till the end of the year. The disclosures of the surgeons would be on the Endourology website. You can at any time tap in and watch the entire session online as of next week.

Dr. Jihad Kauok:

So back to the session of today. We will start by 20 minutes presentation by Dr. Tewari followed by 20 minutes by Dr. Richard Gaston and the last 20 minutes will be for discussions.

Dr. Jihad Kauok:

During the presentation of Dr. Tewari and Gaston we will have an active chat box in which all three moderators will be answering your questions live by the chat box. A few questions will be left live to discuss with the surgeons in the last 20 minutes of this session. So please keep the chat box live and open. Share with us. We welcome all your opinion, questions, and we will do our best to answer your questions.

Dr. Jihad Kauok:

I mentioned about the CME. This the link to the way of earning the CME and for future registration of the seminars. Thank you so much for your time. Without taking more time of our valuable surgeons, we'd like to introduce Dr. Ash Tewari to start with his presentation. Dr. Tewari.

Dr. Ashotsh Tewari:

Thank you, Jihad, for organizing such a wonderful master class. With colleague like you and Dr. Sundaram and Tom Ahlering and everyone moderating it it's going to be an exciting time. And Dr. Guston and I have done this together in the past. I think we are up for an exciting discussion.

Dr. Ashotsh Tewari:

I'm going to share my screen now and I will start with showing something which I call it as a hood technique. So I hope everyone can appreciate the screen. What I'm showing is a robotic prostatectomy in an intermediate risk prostate cancer who I'm planning to do what I call a good no sparing. My technique here is also known as a hood technique because it tends to save the structures in the space of radius as highlighted by Robert Mars and Dr. [Bucharlie 00:05:43].

Dr. Ashotsh Tewari:

They are the structures in the front of the prostate are equally important for the continence. I have developed this approach which allows you to get to the front of the prostate inside the bladder without actually going through the pouch of Douglas. Here you are seeing me not exposing the pubic bone, not exposing much of the tissue, just making a small tunnel and getting to the bladder right in the front.

Dr. Ashotsh Tewari:

Now, I am developing the posterior bladder dissection. I will go through the mucosa. I will identify what I call the retrotrigonal layer. I have been able to see the ureteric orifices without any problem. I can handle any small or big, medium, load with this approach, but what I have not done is to violate any structure which is a continence specific structure in the pouch of Douglas or in this space of ridges.

Dr. Ashotsh Tewari:

After finding the retrotrigonal layer, which I right about here, I will slowly start opening the plane which exists between retrotrigonal layer and vas deferens. It's a very deliberate process and if we are aware of where the vas deferens, we can develop that plane. There is a compartment of its own behind the retrotrigonal layer which houses both seminal vesicles and vas deferens, some vessels. You can see shining vas deferens right in the midline. I am expanding this incision to have a little larger window there.

Dr. Ashotsh Tewari:

Next step for me would be to make it a little wider on the right and left side still staying in the midline. I have not opened the endopelvic fascia. I have not done any other dissection other than staying in the midline. I have picked up one of the vas deferens. I will do the least to get a little bit of a stem of the vas deferens using very small burst of the cauteries to get to that. I will transect the vas deferens. Now, I'm going for the next side of the vas deferens, the contralateral one. Once we have enough length of vas deferens, I can literally pull it out and that attraction to the seminal vesicles and both vas are in my photom.

Dr. Ashotsh Tewari:

Now I'm developing what I call a medial vascular plane medial to the seminal vesicle. There is a unique compartment within the [inaudible 00:08:47] fascia in which seminal vesicle is housed. I will finish the dissection medial as much as I can. There's almost a very vascular plane there. I will lift the structures that will tense up the vessels which are supplying the seminal vesicle. I will clip them individually, sharply cut. Keep developing a plane between the vas and seminal vesicle with the least amount of cauter uses because nerves are never too far from this area, but here I'm almost on the seminal vesicles.

Dr. Ashotsh Tewari:

So once one side seminal vesicle is done, I have picked up both seminal vesicles, and now I'm getting behind the prostate. So I'm developing a plane right in the midline behind the prostate capsule and going as far distally as I can. Understanding the fascia anatomy in this area is very important because these facial layers they actually house the vesicles, they house the veins, they house the nerves, and understanding this is important for us to save what I call the entire neural hammock.

Dr. Ashotsh Tewari:

I'm going for coagulating that blood vessel and cutting it and then developing the plane very deliberately there. Once I have developed the plane in the midline, I will develop the vertical, which is right in the medial aspect where the seminal vesicles are joining. I will develop that proximal medial pedicle on either side. Small clips will allow me to very precisely cut and dissect out these perforating vesicles into the base of prostate or in the seminal vesicle.

Dr. Ashotsh Tewari:

I work left and right based on how the anatomy is presenting. As you can see it's mainly the sharp dissection and I'm developing a small pedicle to guide them sharply. At this point I will try to find the perfect plane between the capsule and the thrombus vein on this side. You can see there's a little bit of inflammatory tissue and you have to make a judgment that whether you want to cut it sharply or slowly dissect it out.

Dr. Ashotsh Tewari:

I'm done with the proximal dissection on the left side. Now I'm coming to the interior part of the prostate, which I call it the hood development. Having an expert assistant like Mr. Roy Berryhill on the patient's side is an great asset. I will now do the same thing on the right side and as this patient has more on the right side in terms of the cancer I'm just taking my own time to find the right plane. It's not a bad idea to have it sharply cut and then slowly develop the plane as it goes along.

Dr. Ashotsh Tewari:

Once I have developed the plane, behind I will try to match more anterior and anterior I will be a little bit closer to what I call the hood. As you can see the entire interior part is saved. And these are the perforating blood vessels at the base of the prostate on the right side. I am developing a small pedicle and clipping it. Once we have a clip in place we can see that these are the veins which are on top of the capsule.

Dr. Ashotsh Tewari:

You can appreciate that I have not dissected the apex so far. I have not opened the endopelvic fascia. You can still not see the pubic bones and the entire thing has been done with a small tunnel, which allowed me to see inside the bladder, inside the interior so that I can appreciate where the ureter orifices are. If there is any medial lobe, I can make the bladder neck small or big based on what the anatomy permits. I have yet not violated the pouch of Douglas. And I have saved the structures in the front, which I call the hood structures, and they are the important component of anterior continence mechanism.

Dr. Ashotsh Tewari:

I do use a little bit more cautery in the front. And based on the patient's anatomy and based on if the patient has a transition zoned tumor, interior tumor, or a posterior tumor, I can modify my operation to make this hood thicker or superficial. I can stay superficial to the vein, I can stay deeper to the vein, depending upon how much of risk I have for having a post hemorrhaging.

Dr. Ashotsh Tewari:

You can see this is the hood structure and we have anatomical studies to understand what structures that comprise the hood. As always we are trying to be cognizant of how closely the structure's emerged near the apex both in the front and in the backside. I'm trying to develop a plane.

Dr. Ashotsh Tewari:

I'm maximizing the length of the membranous urethra while preserving all the pubic prosthetic complex, the pubic prothetic collar, [inaudible 00:16:23], pubal urethral part, and copious amount of what I call the detrusor apron. It's a very deliberate and slow process here.

Dr. Ashotsh Tewari:

I can see the puboperinealis muscle. I can see the external sphincter. I have saved the entire interior coverage of that. And this is a slow and steady dissection of the apex. As we know that the important structures converge now near the apex, I have been very slow and deliberate in this part. I will put in a bob suture on two sides of the urethra getting a good posterior bite and it is done on either side.

Dr. Ashotsh Tewari:

As Dr. Rocoo would appreciate, I am a believer of using [crosstalk 00:18:11].

Dr. Bernardo Rocco:

[crosstalk 00:18:11] from the audience. This is Bernado. Hi. Great to meet you again.

Dr. Ashotsh Tewari:

Hi.

Dr. Bernardo Rocco:

They are asking how to take care of atypical margin during the dissection.

Dr. Ashotsh Tewari:

I mean, understanding where the tissue is and reading about the MRI and recognizing the tissue, if it is not looking right, go distal and be ready to modify the dissection if ... And we, for us, we do what we call neuro safe. So I will get in real time [inaudible 00:18:43] report right then and there and, if it's needed, then I will go in and excise more tissue.

Dr. Ashotsh Tewari:

But right now I think, Dr. Rocco, you should highlight that what I did was the modified Rocco stitch and I think you are most appropriate to answer any questions about that. Depending upon whether or not the bladder neck is big or small I can sometimes reconstruct it. Sometimes I will do more [inaudible 00:19:11]. Sometimes I will leave the bladder neck a little wider.

Dr. Bernardo Rocco:

Thank you very much for quoting this technique. I know that you are one of the first who helped spreading this approach.

Dr. Bernardo Rocco:

And I just take advantage of also making a second question from the audience regarding the comparison between the hood technique and the Aphrodite veil. I get a reply that I think this is even more conservative on the anterior collar, but I think that the audience is happy to hear from your voice what is the step ahead with the hood technique beyond the Aphrodite veil.

Dr. Ashotsh Tewari:

So you already have the Aphrodite veil results available. And that I don't think had a continence to data which was as good as the original space. And I don't think the veil of Aphrodite discussion involved the [inaudible 00:20:11] discussion. It mainly involved the discussion about how the interior release of the neurovascular bundle.

Dr. Ashotsh Tewari:

So the midline saving what Dr. Bob [Meijer 00:20:22] says [inaudible 00:20:22] was not part of that discussion. So this one involves every benefit of what we do in very extensive grade one nerve sparing, but also saves the detrusor apron discussion.

Dr. Bernardo Rocco:

From the audience they would like to know which kind of suture are you using and the length, and the size of the needle.

Dr. Ashotsh Tewari:

This is a RB1 needle and it's a bob suture. And it's a self-dissolvable suture. And I don't use V-Lock in the mucosa. I do use it.

Dr. Ashotsh Tewari:

Give me second. Let me get the lights up because it has an automatic light. If I'm not moving, the light in the room goes away. So give me a second. I'll get us some light. And I'm back.

Dr. Ashotsh Tewari:

So this is a bob suture and I use an absorbable bob suture, like monochromal kind of a thing for the inner layer. And once this layer is done, then the outer layer I use a V-Loc, which is a stronger suture but takes a little longer time to get absorbed. And it's a 3.0 suture.

Dr. Bernardo Rocco:

And if you need to do a little dissection do you perform it before or after prostatic dissection. This is [inaudible 00:21:56].

Dr. Ashotsh Tewari:

I usually do it afterwards.

Dr. Bernardo Rocco:

All right. Thanks.

Dr. Ashotsh Tewari:

If it is at least a nine, I will do it before. But if it is ... Usually I will do it afterwards. In this patient the anatomy was like that, that I had to do and anterior racket handle and you don't have to see the whole part of it so that we can have more time for the questions if you need it.

Dr. Bernardo Rocco:

[inaudible 00:22:36] is from [inaudible 00:22:38]. Thank you.

Dr. Ashotsh Tewari:

And now, I am just closing the anterior part. And by this time I have heard back from the neuro save that things were clean and I can ...

Dr. Ashotsh Tewari:

So what you just saw is bringing in the best of the nerve sparing discussion because we are using it in athermal. We are minimizing the traction. We are staying in a deeper plane. We are doing a grade one nerve sparing. We have saved every structure in the pouch of Douglas. We have been able to see where the ureteric orifices are. If there was a median lobe, I can tackle it. And I have saved the structures and the space of radius.

Dr. Ashotsh Tewari:

I have data at the end. When someone is having a question about comparison between other techniques of the continence we can talk about it. But this definitely speeds up the continence in comparison to me doing the surgery five years ago when I knew what the veil of Aphrodite discussion was or other nerves baring. It brings in the contents at least three months earlier. That's the main benefit of this thing.

Dr. Ashotsh Tewari:

And this is very adaptable for any urologist who has been doing the robotic prostatectomy from the front of the bladder. They can get to it. They can modify based on the median lobe. They don't have to worry about that what happened to the ureteric orifices. If there is indeed more cancer, I can open up one side in the pelvic fascia. I can do hood on one side and not do hood on the side because there is a cancer touching more anteriorly on the MRI before that. These are the sort of modifications I can do.

Dr. Ashotsh Tewari:

I will stop my presentation here and give it to my colleague Dr. Guston to present his brilliant surgery. And then we can all have a discussion together. And I do have some PowerPoint slides which I can show there.

Dr. Jihad Kauok:

That's wonderful. Thank you so much, Dr. Tewari for this amazing presentation and really eye opening approach. Yet another approach that makes total sense presented elegantly. You convinced me to give it a try myself.

Dr. Ashotsh Tewari:

Thank you.

Dr. Jihad Kauok:

So next would be Dr. Gaston from Bordeaux. The podium is yours. Please proceed.

Dr. Richard Gaston:

Okay. It's really a great privilege for me to be with you. The philosophy to treat a cancer, to remove the prostate, but also we want to have a good functional result. With conventional technique we are seeing that the continence was very fine, but we worked a lot to try to preserve more and more and more continence.

Dr. Richard Gaston:

I learned a lot from an open surgeon and in a very important team they taught me some years ago that the reason the open way for potency was better than in [inaudible 00:26:00] approach. And after a lot of discussion we have seen that the difference was in the [inaudible 00:26:08] retrograde dissection, especially in the base of the [inaudible 00:26:12].

Dr. Richard Gaston:

So using the technique of Dr. [Buchardi 00:26:17], using the technique of open way, I have modified more or less my technique to try to adapt more and more surgery to have a good function [inaudible 00:26:32]. So I think there is one technique for one patient. And the case we'll see here today is a new patient with a moderate risk [inaudible 00:26:44] to cause on the right side and the size of the tumor on the MRI was nine milometers. So I want to show you the video now.

Dr. Richard Gaston:

This is the [inaudible 00:27:01] and I just cut the right umbilical artery. And you see that I dissect leaving the fat on the permease whole. It's not necessary to remove completely. And I go directly to the pelvic fascia. And for me, one important step is to see the lateral area of the bladder neck.

Dr. Richard Gaston:

There are some vein going to the dossal vein complex and that I use for many years a clip of 5 milometers to cut this vein. And I just push the origin of the vein at the base of the prostate with the scissor just to dissect the lateral part of the bladder neck. And this plan is generally completely vascular and you see at the tip of my scissor the implantation of the seminal vesicle.

Dr. Richard Gaston:

So I just hold the bladder neck and you see at the beginning of the dissection I have a global vision on the [inaudible 00:28:23]. So open the [inaudible 00:28:28] fascia by very, very, very height like open surgeon and you can see the two layers of the under pelvic fascia. We are at the level of the right tubal prostate ligament and I will dissect completely the bundles without dissection of the seminal vesicles. I push down the bundles on the right side.

Dr. Richard Gaston:

You'll see the two layers of the pelvic fascia. Now, I will control the big vein going to the dorsal vein complex. And then I will have good vision on the bundle. This is the visceral part of the under pelvic fascia. It's a completely automatic dissection. I use the scissor to push the pelvic fascia. We are outside of the [inaudible 00:29:42] and we will reach more of the epics of the prostate.

Dr. Richard Gaston:

Now, you can see the lateral aspect of the bladder neck the seminal vesicle. I can create the space by dissecting a little bit more the bladder neck. You can see the seminal vesicle. This is the left seminal vesicles here. We are under the bladder neck and the gas is helping us to open the space.

Dr. Richard Gaston:

Now, I will dissect the implantation of the seminal vesicle. We can have a dissection about the opportunity to leave the tip of the seminal vesicles.

Dr. Richard Gaston:

The first surgeon giving me this idea was Erst [Studer 00:30:50]. Studer told me that for him it was nonsense to remove completely the seminal vesicles. See this is plane between the [inaudible 00:31:03] fascia and the right seminal vesicle. It's possible, of course, and I do sometimes complete removal of the seminal vesicle, but we have a nice vision on the [venders 00:31:17] and you can see that we present completely the venders at the base of the prostate.

Dr. Richard Gaston:

This is the donoveia fascia. I push it very, very slowly and now the main pedicle are controlled like Dr. Tewari I leave a little bit outside of the prostate. You see? I leave two or three milometers and I push the donoveia fascia to the left side.

Dr. Richard Gaston:

We have a good global vision on the right vender. Now, I cut the seminal vesicle. One of the advantages for me is not to do any traction. You can see the Denonvilliers' fascia and the, at this level, the main vessel going to the left lobe.

Dr. Richard Gaston:

We are under the left base. You can see the small vessels. We can clip the small vessel while cutting them. We have to cut this vessel because if we push this vessel at this level we cannot budge it. And, of course, our main objective is to cure cancer. So I use the progress to go down the prostate more and more to the left.

Dr. Richard Gaston:

Now, I will prepare the apex of the prostrate. You can see the Denonvilliers' close to the apex of the prostate. And I like very much to prepare the urethra laterally and posteriorly. This is bleeding a little bit because we never use any, any cauterizing. So now we are in a good plane. You see we are dissecting the left lobe by posterior approach.

Dr. Richard Gaston:

And now we are going to see the difference between prostate and the bladder at the base. This is fat tissue. We have cut the fibers coming from the bladder and going to the posterior lips of the prostate. This is more or less [inaudible 00:33:47] plane. And now we leave the catheter in the bladder neck to have a good vision. So it's easy to see the difference between bladder and prostate.

Dr. Richard Gaston:

When we have a large median lobe, of course, by this way we can dissect it very easily. You see the left seminal vesicle. The left prostatic. And we are beginning to cut the bladder neck. After controlling the last vesicle you see perfectly the left lobe with the limit between fat tissue and prostatic capsule. And I cut the left vas deferens. We can use clip. And after dissecting I leave the tip of the left seminal vesicle. So you can see the left basin of the prostate with the left pedicle.

Dr. Richard Gaston:

We are exactly in the same situation that we have seen previously with Dr. Tewari with control of the vessel and the base of the prostate. You can see the prostate captures. So now you see the posterior aspect of the urethra. The difference between the fibers of the bladder and the prostrate. We can adapt the surgery, of course, for the patient.

Dr. Richard Gaston:

Is for me the main technique to have a good early continence. I never use this technique, of course, when I have a big tumor or at risk tumor. And what is interesting now is to dissect between prostate and bladder and to preserve the dorsal ventricle complex and the fibers that we call the aprons. The aprons of the bladder. There are muscle fibers coming from the bladder neck and going to the [inaudible 00:37:01].

Dr. Richard Gaston:

I see now the bladder neck. I cut it. I can use cautery, of course. It's important to have a vision on the catheter and I always ask my assistants if the catheter is in place. And you see the plan of dissection that we are using when we were doing prostatic [inaudible 00:38:05]. During that approach the fibers of the bladder there is really a clear plan internally.

Dr. Richard Gaston:

Now we cut completely the bladder neck. Now we have just to push the bladder from the prostate. This is the anterior dissection. You can see the bladder neck at this point. When we push the fibers we can adapt the section, of course, the tumor site. I push the fibers. We will have a vision on the left apex. Just pushing delicately. Now the prostate is completely free. You see the urethra and we have a good vision.

Dr. Richard Gaston:

We will speak about the margin, of course, but it's very interesting to turn completely around the apex of the prostate to try to avoid my margin of [inaudible 00:40:13]. So I push very carefully the bladder. We can cut more or less some vein if it's necessary. In that case, I preserved completely the apex and the [inaudible 00:40:32] and you can see the urethra with the muscles.

Dr. Richard Gaston:

And we have exactly the same vision that we have seen previously with Dr. Tewari, a complete dissection of the urethra. And we will cut the urethra, the good [inaudible 00:41:05]. We can adapt, of course, the dissection of the urethra. We can see the catheter.

Dr. Richard Gaston:

We see the bladder neck, the cavity where was the prostate, and I do a running suture. I use a V-hook 3.0 with a continue suture. The needle is a 17 millimeters. So generally we have no great difficulty to do this. [inaudible 00:41:52] outside. I do a Rocco stitch, of course, when I need a Rocco suturing. When I [inaudible 00:42:06] five. For example, when I do a large dissection. But in that case I think that is not necessary.

Dr. Richard Gaston:

And we are seeing how that does at the level of continence, of course, is very high to immediately. So now we put the catheter in the bladder and I close with the same stich the opening on the right side of the under pelvic fascia.

Dr. Richard Gaston:

So I am open to the discussion.

Dr. Jihad Kauok:

Thank you so much, Dr, Gaston. As usual very elegant surgery and very educational. We will open the podium to our moderators for questions they accumulated from the attendees online and also for them to address questions to you and to Dr. Tewari. So I will leave the podium to the moderators at this time.

Dr. Thomas Ahlering:

Can we address your outcomes, the early continence, and the sexual function?

Dr. Ashotsh Tewari:

So this is ... Sexual function is tied to the grades of nerve sparing. If I do a grades of nerve sparing just the way I did it in this patient, he has more than 87% chance by end of the one year he will be able to have sexual function with the use of pills. Second and third year, 50% of these patients don't need a pill, but most patients do need a pill.

Dr. Ashotsh Tewari:

The continence discussion is here. As you can appreciate this is ... The blue line here is continence in my own hand about five to 10 years ago. The red line is with the hood technique in which I'm saving the interior structures. I'm getting to the same point in four weeks, which I used to reach in about three months. That is the only difference I am seeing.

Dr. Ashotsh Tewari:

When you compare it to the other reduced sparing studies they are comparable but there is a difference in the technique which I showed. At seventh day the results will be much more favorable for the reduced sparing approach. But at four weeks and six weeks the results are comparable. And then, as you go from that point on the red line shows that what the continence rate are for the use of that.

Dr. Ashotsh Tewari:

These are the past margin rate. My past margin rate, this is the study which we are talking about, are 3% and 5% in this thing. And it hasn't changed much in the past few years because I'm doing the neuro safe procedure.

Dr. Ashotsh Tewari:

And I will not do the same technique if someone has a high risk of extra capsular extension because we use what we call Alberto's nomogram, which is an MRI based nomogram. So important thing for the technique is it is not applicable to every patient. Second, we have to do the grades of nerves pairing discussion and patients who have more extensive cases are not a candidate for nerve sparing.

Dr. Ashotsh Tewari:

Patients who have an anterior radical cancer or who have an anterior tumor in the anterior fibralamaculoastroma, I will not be using the same technique. I many use the partially same technique if someone has a left sided protuberance in the anterior part, but right it totally free. I can do what I call a unilateral hood and the continence reserves accordingly change. Meaning the delay in continence happens in those patients in whom I cannot do the whole hood.

Dr. Ashotsh Tewari:

But if we modify it to the right patient, I think the results are as they used to be. The sexual function of those should not be any different. Continence is earlier, but not on the same day of the day of the cath removal.

Dr. Thomas Ahlering:

And again, the continence is no pads?

Dr. Ashotsh Tewari:

That's correct.

Dr. Jihad Kauok:

That's great. Wonderful results. Dr. Rocco, you had questions we asked you to leave till the end?

Dr. Bernardo Rocco:

Well, I collected some from the audience, if you want I can share with the panel. And one first is on the [inaudible 00:46:42] construction of bladder neck [inaudible 00:46:44] regarding Dr. Tewari's case. Second question, for Dr. Tewari from Joseph [Macaluso 00:46:50], do you believe open radical prostatectomy using [inaudible 00:46:53] modification can achieve comparable results? I would move on with these two questions.

Dr. Ashotsh Tewari:

Let's answer the second one first. I think the tools don't make you a better surgeon. What you do with the tools is what defines the outcome. So open and robotic discussion we used to tackle that 10 years ago, 15 years ago, I still believe with your scalpel or do with you [inaudible 00:47:20] is important.

Dr. Ashotsh Tewari:

I have seen Tom Ahlering do open radical before. I have seen [Jasmid 00:47:25] doing an open radical before. And then I have seen both of them doing a robotic. The surgeons temperament doesn't change. So you can do exactly same operation with open or robotic or even laparoscopy. I have seen [Buteron 00:47:40] [Guierno 00:47:40] doing a laparoscopy radical prostatectomy and he's amazing. So the tool discussion is not.

Dr. Ashotsh Tewari:

And I don't do the bladder neck reconstruction if bladder neck is very small, but if it is bigger then I usually do a combination of Rocco and [Pergano 00:48:00]. Both Italian names, but they help me. And so you will know which bladder neck needs to be reconstructed and which can be done just with an anterior one and which can be done with a posterior one.

Dr. Ashotsh Tewari:

By the way, this is a picture of how I conceptualized the hood. And that I think people can appreciate. This is far behind the whale discussion. Whale is on the lateral side. And these are the hand drawings done by me to kind of understand what structures I'm trying to save.

Dr. Jihad Kauok:

Great. A question from the audience also about rectal injuries and selection criteria to Dr. Gaston.

Dr. Richard Gaston:

Yes, I think the best option to do this technique is to have a very well-motivated patient to recover potency. And I never do this technique when I have a tumor on the apex of the prostate. It's more and more easy today to see where is the main site of the tumor because the MRI's more and more precise.

Dr. Richard Gaston:

In our institution we use also a sonography by Exact Vision and before operating on the patient I do this sonography to try to see the limit of the cancer. So for me, the main indication is when we have a posterolateral tumor, small size, less than 20 millimeters without any risk for T3 and when [inaudible 00:49:49] score is under 4.3. At 4.4 I may use this technique. 4.5 I never use this technique. When I have a big tumor that invades the prostate I don't do this technique.

Dr. Richard Gaston:

Today this technique is around 40%, 45% of our patients and we have to select. We have to select the patient. When I have a decent score, 4.3 for example, I always remove the seminal vesicle.

Dr. Richard Gaston:

So I think we had a discussion some weeks ago with Dr. Tewari and we have seen that there is one surgery for one patient and that with experience we can adapt the surgery to each case. And with many, many, many technique we can choose the main [inaudible 00:50:46] patient. We never, never repeat the same technique.

Dr. Thomas Ahlering:

A question for both surgeons. Does the impact of the assessment of sexual function dramatically change what you will offer to the patient? In other words, if there IF5 is below some threshold number, 22, 20, will that change your approach for offering the nerve sparing? And also, what effect would age have on that?

Dr. Richard Gaston:

Dr. Tewari, you want to ...

Dr. Ashotsh Tewari:

Yeah. I think this is tied to the second discussion. I think saving nerves will not impact continence above and beyond sexual function recovery. So my simplified approach is I think somehow when I save more nerves patients tend to be a little better continent.

Dr. Ashotsh Tewari:

So even if someone doesn't have a sexual function, by given a choice I will try to save the nerves, but ... There is a but, I may not do the grade one nerve sparing in a [inaudible 00:52:11] seven four plus three. I will do a little bit more conservative nerve sparing.

Dr. Ashotsh Tewari:

So I did save the nerve. I didn't put his margin rate at risk for a so called sexual function advantage, but it doesn't exist for him. But I did do everything so that his continence gets resolved.

Dr. Ashotsh Tewari:

And Tom is very thoughtful when he brought in the age discussion in there because older people are more likely to be incontinent for a longer time. So whatever we can do at the time of surgery to minimize their incontinence issue. So yes, I will save the nerves not just for the sexual function but for the continence also, but I will not be very aggressive in term of which grade of nerve sparing concept which I'll be using.

Dr. Ashotsh Tewari:

Does that answer it, Tom"

Dr. Thomas Ahlering:

Well, I think it does. It addresses some important issues. I think that most of us can see that as we really refine our surgical technique we can definitely help improve the overall outcomes of continence, but sexual function is less easy to do so because it's so often driven by the patient. We can dramatically improve our technical, but it they don't start with good enough sexual function or if age is a limiting factor. I mean, certainly we want to offer that to all patients, but I was just really kind of wondering in your practicality what do you see.

Dr. Thomas Ahlering:

That's certainly what we've seen is that we've been able to have significant improvement in continence but the sexual function, if somebody comes in with inadequate sexual function, even though we're being as careful as we can, we can't seem to get over that same hump that we've been able to do with continence.

Dr. Jihad Kauok:

I'm totally with you. So sexual function recovery is partly neural, partly venous, partly endocrine, and partly inflammatory. There are things we can do for the neural part. There are things we can do for the mechanical trauma or the terminal trauma or the tactile trauma, but we cannot change the biology. We cannot change the [inaudible 00:54:21] issue. We cannot ... I mean, they are at the brink of just getting into bad outcome because their vasculature is there. So all that combined.

Dr. Jihad Kauok:

So we have a program in which they will be meeting [Durran 00:54:34] [Stimba 00:54:34], [Gurard 00:54:34] [Venezuela 00:54:34], or Rod [Corohead00:54:36] beforehand so that they can have a conversation as to what it takes to have a rehab. And it's not just in the operating room. It is before and afterwards both.

Dr. Thomas Ahlering:

[crosstalk 00:54:47].

Dr. Jihad Kauok:

Okay, we have only one minute. Move one. Sorry.

Dr. Bernardo Rocco:

Two very good questions if I can from the audience. One is very interesting from Dr. [Seferoush 00:54:55] who reported he's experienced some 1,000 cases of sutureless radical prostatectomy. If you have experience, what do you think about it? And the second question for both of your is the learning curve of your techniques?

Dr. Richard Gaston:

About the sutureless, I think, one of the main reasons of incontinence sometimes is fibrosis at the level of the suture. So I think when we have a good quality of [inaudible 00:55:25] we have less fibrosis and better recovery of continence. So I think today especially was rebel. We can do very, very simply a good suture. So less suture, for me, not the future.

Dr. Richard Gaston:

And the learning curve. So like Dr. Tewari we did 1,000 and 1,000 radical prostatectomy and we are still in learning curve. So we learn every day. Every day I have no solution to know how to preserve potency for example. We have better and better results, but we have no solution. So I guess it's experience. It's impossible to give a number precise of patients to learn perfectly how to remove a prostate.

Dr. Ashotsh Tewari:

I will echo Dr. Guston's feelings. I have got to no experience with the sutureless technique so I will not address that. But as regards to the learning curve, I still remember in 2000 when I was doing the first case with Dr. [Mennin 00:56:46] and I in United States. We took such a long time. But the current technique which I am showing is an easily adaptable. That's all. It's an incremental change from a technique which we normally use and most of us can adapt to that then making a drastic change in our approaches.

Dr. Jihad Kauok:

Thank you surgeons and moderators for joining us today. Thank you Dr. [Klinbotter 00:57:12] for being the back administrative work going on and keeping this on track. And thank you Michelle [Poli 00:57:21] for your amazing work to deliver on our promise for every two weeks. Thank you all.

Dr. Jihad Kauok:

I would like to remind you of our next session. That's going to be August 14th at noon and the topic will be about robotic radical cystectomy. Thank you all. And have a wonderful weekend.