Surgeons: Koon Ho Rha, Rabii Madi

Moderators: John Davis and James Peabody


Rha, Koon Ho MD PhD FACS

Professor of Urology / Director, Yonsei Robotic Training Center

Chief Strategy Officer, Yonsei University Health Systems

President, Korean Endourological Society

Dr. Koon Ho Rha is Professor of Urology and Robotic and Minimally Invasive Surgery Center. He received both his premedicine education magna cum laude and his M.D. degree from the Yonsei University, Seoul. Dr. Rha was trained during his urological rotating residency training at the Mayo Clinic in Minnesota. He underwent fellowship training in minimally invasive and laparoscopic surgery at the Johns Hopkins Medical Institution as Engineering and Urology endowed fellow, and served as visiting Assistant Professor in Urology at the Johns Hopkins University School of Medicine. During his stay, he also completed “Business in Medicine” a 1-year MBA program at the School of Business Administration and Education.

Prior to his return to Yonsei in 2003, Dr. Rha obtained extensive experience in minimally invasive and laparoscopic surgery at Yonsei University and co-invented a novel surgical procedure “Video-Assisted Minilaparotomy Surgery (VAMS)”, which is now commercially available through Thompson Surgical, Inc. Later at Johns Hopkins, he continued his interests in the field of minimally invasive surgery/laparoscopy, and conducted further scientific studies with Dr. Louis R. Kavoussi, the leading pioneer on laparoscopic and robotic surgery. Dr. Rha set up the robotic surgery program at Yonsei University in 2005 which now has the most robotic cases as a single hospital in the world with 25,000 cases. During last 15 years, Dr. Rha has performed the most cases in Asia with more than 3500 cases of robotic cases including  3000 cases of robotic prostatectomies. With cumulative experiences, Dr. Rha’s team developed world’s first robotic approaches of nephroureterectomies and single-incision partial nephrectomies. His research interest includes robotic platform and device development, and Dr. Rha successfully completed Korean surgical robot clinical trial which resulted in KFDA approval in August 2017. He has given more than 550 lectures on robotic surgery and performed live surgery or proctored more than 60 occasions in 15 countries including US, China, Japan, Taiwan, Czech Republic, Singapore, Hong Kong, Saudi Arabia, India, Malaysia, Italy, Kuwait, Vietnam and France.

Dr. Rha has more than 350 peer-reviewed scientific publications on minimally invasive urological surgery. He was the editor of Korean Journal of Endourology and serves as reviewer for Journal of Urology, Journal of Endourology and Journal of Robotic Surgery. He is the President of Korean Endourological Society and Past-president of Urology and Engineering Society in US. On administrative side, he has served as the Associate Dean of Faculty Affairs, Chief Operating Officer and the Chief Strategy Officer at Yonsei University Health System.

 

Rabii Madi, MD, MBA, FACS

  • Professor of Urology
  • Director of Urologic Oncology and Robotic Surgery at the Medical College of Georgia-Augusta University Health.
  • Past-President of Georgia Urologic Association
  • Board of Directors: American Urological Association SES
  • Fellowship: Urologic Oncology and Minimally Invasive Surgery, University of Michigan Medical Center, 2004-2006
  • Residency: Urology, American University Hospital, Beirut, Lebanon 1998-2004.

Dr. Madi is a urologic Oncologist and a minimally invasive surgeon who has specific interest in robotic surgery. He was the director of Robotic surgery at Case Western Reserve in Cleveland before moving to Georgia. He has performed more than 2000 robotic surgeries and has several peer-review publications. He is among the early adopters of Retzius sparing robotic prostatectomy in the US and has performed more than 300 cases so far.

 

James O. Peabody M.D., F.A.C.S

Vice Chair, Department of Urology, Henry Ford Hospital
Vice Chair, Board of Governors, Henry Ford Medical Group
Email: This email address is being protected from spambots. You need JavaScript enabled to view it. 

James O. Peabody, M.D., is a senior staff member of the Vattikuti Urology Institute (VUI) at Henry Ford Health System in Detroit, Mich. He received his medical degree from the University of Michigan Medical School in 1985. He completed his residency training in Urology at Henry Ford Hospital, finishing in 1990.

His specialties include urologic oncology and robotic assisted laparoscopic prostatectomy. He worked with Dr. Mani Menon to help develop the first structured robotic surgery program in the world. He has served numerous leadership roles in the department and Henry Ford Health System, including Urology Residency Program and is currently the Vice- Chair of the Department of Urology and Vice-Chair of the Henry Ford Medical Group Board of Governors. He is known internationally for his skill and passion as a teacher. He has been awarded the VUI Resident Teaching award on several occasions and received the Resident Teaching from the American Urological Association.

Dr. Peabody is a member of multiple professional societies including the American Medical Association, the Michigan Urological Society, the American Urological Association, the American College of Surgeons, the European Urologic Association and the Societé Internationale d’Urologie. He has authored over 200 peer reviewed journal articles and book chapters. He helps lead a statewide quality improvement initiative for prostate cancer treatment in Michigan (MUSIC) and has helped lead multiple medical missions to West Africa and Honduras. Dr. Peabody is very dedicated and strives to bring exceptional outcomes to patients all around the world.

 

John W. Davis, MD

John W. Davis, MD, is a Professor of Urology and Director of the Urosurgical Prostate Program at the University of Texas MD Anderson Cancer Center in Houston. Dr. Davis had fellowship training in prostate cancer research in the Department of Microbiology and Molecular Cell Biology at Eastern Virginia Medical School, and received an American Foundation of Urologic Disease Scholar award for proteomic applications in prostate cancer.  His academic interests include quality of life after prostate cancer treatment, outcomes for robotic radical prostatectomy, high-risk prostate cancer trials, active surveillance for prostate cancer, and development of robotic surgical techniques for invasive bladder cancer.

 

Webinar Transcript

Dr. Chandru Sundaram:

Hello, I'm Chandru Sundaram welcoming you to this robotics webinar on behalf of Dr. Adrian Joyce, the Endourological Society, and the Society of Urologic Robotic Surgeons. Join us every two weeks until the end of the year for expert faculty moderating technique based webinars on robotic surgery. You will get CME credits for these webinars, and you will have instructions on how you should receive these credits. Also, in case you miss part or all of these webinars, they are available on the Endourological Society as well as the SURS website. Please consider joining our society and being a member. There are multiple opportunities and member benefits. On behalf of the Endourological Society and SURS, I am delighted to introduce to you Dr. Dr. Jihad Kaouk, who will be facilitating this webinar with our expert faculty, whom he will introduce. Jihad?

Dr. Jihad Kaouk:

Thank you so much Dr. Sundaram. We are excited to continue with our bi-monthly series of webinars from SURS, the Society of Urologic Robotic Surgeons that's part of the Endourology Society. We have a very exciting program for you today that is focused on the retzius-sparing robotic radical prostatectomy. We will have a format of 60 minutes. The first 20 minutes is going to be presented by Dr. Dr. Rabii Madi, and Dr. Madi is a professor of urology who's done more than 300 retzius-sparing prostatectomies, and he has a center for oncology and robotic in Augusta, Georgia. And after that, in the next 20 minutes, Dr. Koukourikis, who will be joining us from Yonsei University in South Korea, working with Professor Koon Ho Rha, with a vast experience also in the retzius-sparing prostatectomy.

Dr. Jihad Kaouk:

During this 40 minutes, we will have a very active chat box that we welcome all the attendees to put their questions in written, and these will be answered in realtime by our expert moderators, who we're very fortunate to have today, Dr. Dr. John Davis is a professor of urology very well known in the oncology world from MD Anderson, and Dr. Jim Peabody, who is a mentor at large in minimal invasive surgery, and holds many senior titles at Henry Ford Health System in Michigan. So we would like to start with the first session, that will be presented by Dr. Madi. Dr. Madi, please go ahead.

Dr. Rabii Madi:

Thank you Dr. Kaouk, and thank you Dr. Sundaram, Dr. Peabody, and Dr. Davis, for allowing me to share with you my experience with retzius-sparing robotic radical prostatectomy. I will try my best to stick on time of 15 minutes. I'm going to show you most videos and a few slides about our outcome with that.

Dr. Rabii Madi:

So how is retzius robotic radical prostatectomy done? Briefly, the main difference between the retzius-sparing and the regular technique, that part here, number two, which means we remove the prostate below the bladder, we do not drop the bladder, we keep the retzius space intact, and we do that division by keeping all the attachment anterior to the urethra intact. So the first part is posterior dissection, like most of us do, and then we go anterolateral and divide the bladder neck without, from underneath the bladder. This technique, as you know, was first discovered by Drs. Bocciardi and Galfano in 2014 and gradually it is gaining more popularity.

Dr. Rabii Madi:

Why is better? I think, in my opinion, the main difference, and we published that last year, is that when we do the retzius-sparing here on the right side, we have preservation of those three structures, the endopelvic fascia, the puboprostatic ligament, and the dorsal vein, while when you do the conventional technique, typically we cut those structures, and those structures are anchoring structures to the urethra, and maintaining the support and the length of the urethra.

Dr. Rabii Madi:

So in 2017, we published our first experience with retzius-sparing, and you can see we compared 100 regular technique to 100 retzius-sparing technique, and we had the persistent advantage in terms of continence, and that event is persistent at 12 months. Some studies showed that that advantage disappears at 12 months. In our hands, it stayed, and there was no other significant difference in erectile dysfunction, in margins, or complication.

Dr. Rabii Madi:

Last year, we published our 250 cases, and this is briefly the results, and we found that [inaudible 00:05:44] tend to do a little bit less in terms of continence, but we were able to achieve continence in 45%, three months continence 70%, and one year continence 92%. I think the margin rates were reasonable, and we had 6% who had oncologic failure, and 7% had adjuvant medication, 8% had hormone because of lymph node involvement. And you can see here how the continence improved from 45% to 70, 84, 88, and at one year we achieved 92%.

Dr. Rabii Madi:

So there are advantages that are not told and I think are important to mention. That retzius-sparing is a great surgery for those patients who had previous hernia surgery, because you don't have, especially laparoscopic hernia, you don't have to drop the bladder, you don't have to deal with the adhesions caused by the mesh. It's very good surgery for those who had kidney transplant because again, you are preserving the retzius space, and you are not intervening with the anastomosis. Patients with previous IPP. Less incidence of inguinal hernia, this has been published and proved that those who had retzius-sparing have much less incidence of inguinal hernia comparing to the regular technique. We preserve the space of retzius for future surgery, and also I think it's an easier approach for large median lobe that I'm going to show it to you very shortly. And it's always reversible. That's the good thing. For those who are trying to do it, you can always go back and drop the bladder in case you cannot progress, and that could be done at any level, at any stage of the surgery.

Dr. Rabii Madi:

How is it done? For the XI system, it's similar to the regular technique. The patient is in supine position, we'll put them in T-burg, we don't do lithotomy anymore. Do [Veress 00:07:41] needle supraumbilical incision, and then I put five trocars, camera trocar, the scissors, the ProGrasp, and the bipolar and the assistant is halfway between those two. I put the patient in 27 degree T-burg. Put the pneumoperitoneum on 12, and we proceed with the surgery.

Dr. Rabii Madi:

Now, I'm going to describe to you here briefly the main steps of the surgery, and then I'm going to share with you other videos with median lobe, and the last video is going to be about salvage retzius-sparing prostatectomy. So we start with the posterior dissection, we control the vas and the seminal vesicles. So the posterior dissection is done like we do for regular technique. You dissect the vas deferens and seminal vesicles. I think many of us do the posterior dissection, and this is the same with the retzius-sparing and the regular technique.

Dr. Rabii Madi:

So the seminal vesicle is dissected using sharp and blunt dissection. I put a Lapro-Clip. This is my favorite clip that I use during the retzius-sparing or even regular prostatectomy. I like the Lapro-Clip, the absorbable clips, and you don't need to create a window to put those clips, they just go through the tissues, and they stay.

Dr. Rabii Madi:

So the posterior dissection here, you can see after I clear the seminal vesicle and the vas deferens, incise the space between the [inaudible 00:09:21] posteriorly, I do also anterior cleaning of the tissues.

Dr. Rabii Madi:

So the second step is identifying the prostate pedicle and the postero-lateral dissection. And I think this is the key difference here. So far it is like a regular technique. Now, that's the part that is really, I think, the hardest part, is trying to find that pedicle, and the way we do it, we go half centimeter to one centimeter poster-lateral from the seminal vesicle attachment, and we bluntly create that space. Actually you can always find it, and that space is just lateral to the prostate attachment. We create that space, you put the clip, and then you cut, and you can go as wide as you want depending on your plans.

Dr. Rabii Madi:

If you are going to do nerve sparing like here we are doing the nerve sparing, definitely you dissect and you put the clip close to the prostate, and then you cut above that, and this is what I believe is a good advantage of the retzius-sparing, is that you naturally follow the planes of the prostate. You can go wide if you want, and I do it for all high-grade and high-volume disease, because you can go definitely wide, but if you want to follow the intraplanar dissection, it comes naturally. It goes easily.

Dr. Rabii Madi:

So here we did the postero-lateral dissection on the left, we do the same thing on the right side. On the right side is kind of, it's more tricky if you have the ProGrasp on the right, you have to hold the ProGrasp in a way that does not fight with your scissor, but basically the same concept. You create that space bluntly first, and then you put the clip, and that will control the initial pedicles of the prostate, and further you do the neurovascular dropping as you go antegradely.

Dr. Rabii Madi:

(silence)

Dr. Rabii Madi:

So you can see here, we can dissect along the laterally medially and then go with the clip. After you do the posterolateral, we do the anterolateral dissection to identify the bladder neck.

Dr. Rabii Madi:

So the way I like to identify the bladder neck is I go lateral to medial. So I try to develop the antero-lateral tissues. I use the bipolar or the PK here a lot, and those tissues, I grab them, cut them, and then as you are doing that, you can see the funneling of the bladder neck. It comes really very nicely, and you can see how the bladder neck is triangulating around the prostate. I try to go again from lateral to medial, and this is typically how the bladder neck looks like, and that's the bladder neck. You would incise first the posterior bladder neck, find the catheter, deflate the balloon, we pull the catheter out, and then once you have that dissection, dividing the bladder neck is pretty straightforward, takes literally three minutes to do.

Dr. Rabii Madi:

So the bladder neck here posteriorly is dissected, and then after that, we incise the anterior bladder neck, and the go anteriorly to the dorsal vein. This is the anterior bladder neck dissected. I'm going to stop this video and show you a challenging case where we have a median lobe.

Dr. Rabii Madi:

So for regular bladder neck it's easy. The median lobe, of course, is more challenging, but the concept is really the same. This is a large median lobe here, and the idea is the median lobe is going to be facing you. When you do the retzius-sparing, you start with the posterior approach, so you are starting with the posterior bladder neck, so as a result, the median lobe is going to be facing you, and the way I do it, I just incise the seromuscular attachment on the posterior lobe, and then push the bladder neck anteriorly upward until finally you find and you incise the posterior bladder neck, and you can see here there's a large median lobe.

Dr. Rabii Madi:

Once you do that, dividing the anterior bladder neck is really easy and then after, we proceed with the anterior dissection of the prostate. I'm going to show you here the anterior dissection, which is followed also by the anastomosis. So I use bipolar, I cauterize, I cut. I try to go below the dorsal vein, just maybe incise the attachment, but not anteriorly. And I keep doing that until finally find the urethra.

Dr. Rabii Madi:

(silence)

Dr. Rabii Madi:

So you can see now we are close to the urethra, so once we find the urethra, it's becoming like regular case, you incise the urethra at the apex of the prostate. I try to preserve the length of the urethra as much as I could, I think it's crucial, and that's it. And now the prostate is out. After that, we do the anastomosis. This is the same patient with 100 plus prostate with a large median lobe. You can see even with the large median lobe, you can preserve the bladder neck to some extent. And the way I do it here, I do two sutures on the right side and then two sutures on the left side. The anastomosis with the retzius-sparing is definitely harder than the regular anastomosis. It's totally like a mirror image, if you want to call it, from the regular technique. You start with the anterior bladder neck, but once you get familiar with it, it's all backhand suturing, it becomes really straightforward.

Dr. Rabii Madi:

So I take two sutures on the right starting from the anterior bladder neck, and then two sutures on the left, and depending on the size of bladder neck, I take one or two laterally, and then one or two posteriorly, and that should be sufficient. Now you can see the bladder neck here is a little bit larger than a typical retzius-sparing. This is the same patient who had the large median lobe.

Dr. Rabii Madi:

(silence)

Dr. Rabii Madi:

And I use 3-0 V-Loc suture. I'm a big fan of the V-Loc suture. I use it on almost all my cases. On [RV-1 00:16:38] needle, and typically two sutures are in, and those are six inches, you can use the nine if you want to, but I felt the nine is too long, and six inches are perfect.

Dr. Rabii Madi:

(silence)

Dr. Rabii Madi:

So here we do the lateral after the posterior, and at the end we do the posterior bladder neck. I have a question. Am I supposed to answer the questions now?

Dr. Jihad Kaouk:

No, you continue with your presentation. The attendees will get to that later.

Dr. Rabii Madi:

Okay because it popped onto my screen. So now we go through the posterior bladder neck anastomosis. Again, there's some learner curve in it, but it's not that hard once you have that nice exposure. Now, I don't use any anchoring suture. I know it was described early that you can lift up on the bladder, or you can put a suture on the posterior bladder neck or the anterior bladder neck. It might help. I tried it a few times, I did not feel it really makes... I didn't feel that it made my surgery easier, so I try to use my ProGrasp, and most of the time, to give me the retraction I need and I rely on my assistant. I have only one assistant, one port for that assistant.

Dr. Rabii Madi:

Throughout the conclusion you do the posterior bladder neck, and that will be it. If for whatever reason the catheter does not go in and you have hard time on the anastomosis early on when you're practicing doing this case, you can always drop the bladder. It takes 10, 15 minutes to drop the bladder, and open the space and do it the proper way because that's going to be one of the hardest steps initially when learning to do this technique.

Dr. Rabii Madi:

(silence)

Dr. Rabii Madi:

All right. And the last thing I would like to share with you is the salvage. I'm a big fan for retzius-sparing in the salvage setting, and this video is going to be five minutes, but I can stop at any time if I need to. So the salvage retzius-sparing, I have done around 16 salvage retzius-sparing prostatectomies, and the continence result, to my surprise, is much, much, much better than the regular technique. You know when we do salvage prostatectomy in the regular technique, the series and the data published show that the continence rate is around 50%, and that's what I found when I compared my own regular to retzius-sparing salvage.

Dr. Rabii Madi:

With the retzius-sparing the continence rate was far better, up to 100%, actually. Small series, small number, but I'm happily, I'm surprised, but very happy about it that my patients with the salvage are doing far better in terms of continence than the regular technique, but you can see, we do the same step. This guy had two years of, they had traditional therapy, and two years of hormonal therapy. So you can see the planes are not as vascular as a regular. The planes are even harder to identify, they all look yellow. Sometimes its hard to see where the prostate is, where the fat is, where the rectum is, but with proper dissection you can do it, and I've so far been very pleased with the salvage retzius-sparing.

Dr. Rabii Madi:

You can see, the same concept. Identifying the bladder neck, dividing the bladder neck, and then the anastomosis.

Dr. Rabii Madi:

(silence)

Dr. Rabii Madi:

So that's the posterior bladder neck here dissected, and then the anterior bladder neck, and then the urethra. For those who do salvage robotic prostatectomy, as you know, sometimes the surgery goes really straightforward as a regular case, sometimes it's a nightmare. It's hard to predict. I've felt so far that if you do it after the cryo, that's the worst surgery, that's the hardest one. After brachytherapy, usually is not that hard, and after external radiation is reasonable. I felt the worst two cases I've done are both after the cryotherapy. It was whole gland, or whole prostate cryotherapy.

Dr. Rabii Madi:

So we had 26 patients who underwent salvage prostatectomy. 16 were retzius-sparing, 10 were regular, and briefly here you can see there was no difference in terms of the median BMI was around 30, and there's no difference in pre-op characteristics. The console time with the retzius-sparing was 130 minutes, the median was actually less in the retzius versus the regular technique. Bladder neck sparing was achieved in 94% in the retzius versus 40%, and that was significant. Blood loss, believe it or not, even though we don't do dorsal vein stitch, was less with the retzius-sparing.

Dr. Rabii Madi:

The rest here, the continence this is the main point, continence at three months with retzius-sparing was 80% versus 0% with the regular technique. Six months 82% versus 22%. At one year we were able to achieve 100% continence rate. Eight out of eight, we don't have followup on all of the patients yet, versus 44% from the regular technique, and the median time to continence was 90 days versus 270 days, and briefly you can see here, not only the continence was better, the time to continence was much shorter. The IPSS and the quality of life with the retzius-sparing was even better than the baseline value before even surgery. And that's it.

Dr. Jihad Kaouk:

Thank you so much Dr. Madi, and congratulations on your successful series. We have a lot of questions that we will address at the later 20 minutes of our moderated session. Now I would like to welcome Dr. Koukourikis, who works with professor Koon Ho Rha in Yonsei University in South Korea. Dr. Koukourikis have a very impressive resume and a rising star, so we look forward to your presentation. Please go ahead.

Dr. Perikilis Koukourikis:

Greetings from Seoul. First of all, I want to thank the Endourology Society, and the Society of Urologic Robotic Surgeons for this amazing and very educational master classes. I'm very grateful to present the Yonsei technique for retzius-sparing radical prostatectomy. Nothing to disclose. Regarding patient positioning, we use the lithotomy position with the stirrups and we use this position even with the Xi or the SP robot. We have access to the perineum for the perineum compression during the anastomosis.

Dr. Perikilis Koukourikis:

The pneumoperitoneum is established with Veress needle, and the portfolio configuration is the classic six one, but with some modifications. We place the ProGrasp through the medial right port here, and the scissors through the right lateral port, and this prevents from fighting when you lift up the bladder with the ProGrasp. The assistant stands to the left side of the patient, and then patient is placed in [inaudible 00:25:06] position, and the robot is docked.

Dr. Perikilis Koukourikis:

This technique started in Yonsei in 2012, and the steps has been standardized through the years. The surgery starts with bowel mobilization to reflect the colon from the left lateral wall, and prevent any intraoperative bowel injury from the assistant's instruments. So when the colon is fully mobilized, the sigmoid is retracted cephalic, and out of the true pelvis to expose the pouch of Douglas.

Dr. Perikilis Koukourikis:

We deflate the Foley in this step and we make the three to four centimeter horizontal incision to the posterior peritoneum, and this incision is higher to the level of the vas. The space between the bladder and the posterior peritoneum is developed towards the vas deferens and the seminal vesicles.

Dr. Perikilis Koukourikis:

(silence)

Dr. Perikilis Koukourikis:

The assistant is pulling down the peritoneum and the vas deferens is mobilized, and clipped, then dissected. We don't use any stay sutures to pull up the bladder and the seminal vesicles, but the ProGrasp is pulling up the tissues to help the dissection. Moving to seminal vesicles dissection, any arterioles are secured with clips. The trick to avoid too much dissection around the seminal vesicles is to [puncture 00:27:37] and then cauterize them.

Dr. Perikilis Koukourikis:

When the seminal vesicles are dissected bilaterally, the plane posterior to the prostate and anterior to the rectum is developed. In this step, you can choose the plane of dissection. This plane is preferred [inaudible 00:28:07] optics and laterally as far as possible. The prostate pedicle is grasped with the Maryland and clipped with five millimeter titanium clips and dissected.

Dr. Perikilis Koukourikis:

The advantage of using the clips instead of [hemlocks 00:28:31] is that they are not so bulky, so can be placed closer to the prostate, and also they don't need to create a window to the tissue.

Dr. Perikilis Koukourikis:

(silence)

Dr. Perikilis Koukourikis:

Any remaining neurovascular [inaudible 00:28:54] is peeled off the prostate, and then the dissection is moving towards the lateral surface of the prostate, and always, the ProGrasp is lifting up the bladder to help dissection.

Dr. Perikilis Koukourikis:

(silence)

Dr. Perikilis Koukourikis:

The same surgical steps are repeated to the contralateral side, and a combination of sharp and blunt dissect is performed to the lateral side following the curve of the prostate until the apex and the DVC is seen.

Dr. Perikilis Koukourikis:

(silence)

Dr. Perikilis Koukourikis:

Moving to bladder neck, the dissection starts from the outer longitudinal detrusor muscle fibers, and this dissection should be done circumferentially first, to avoid big bladder necks.

Dr. Perikilis Koukourikis:

(silence)

Dr. Perikilis Koukourikis:

The key for the bladder neck dissection is the traction from the ProGrasp, and the counter retraction from the Maryland to tent up the bladder neck and to recognize the circumferential detrusor fibers. Then, the posterior bladder neck is [inaudible 00:30:31].

Dr. Perikilis Koukourikis:

You can appreciate that despite this is a 68 gram prostate, the bladder neck is well preserved. Then the dissection is moving to anterior bladder neck and anterior prostate surface. When to where most of the DVC has been released from the lateral dissection. So now the remaining apical tissues are transected and the urethra length is maximizing.

Dr. Perikilis Koukourikis:

(silence)

Dr. Perikilis Koukourikis:

The urethra is cut close to the apex with cold scissors, and the specimen is placed in the Endobag we use two needle drivers for the anastomosis and firstly, we secure any minor bleeding from the DVC with a figure of eight suture, and we use the same suture every the anastomosis and this is 3-0 V-Loc barbed suture with an [S-8 00:32:02] needle and 25 centimeters long.

Dr. Perikilis Koukourikis:

The anterior bladder neck is anastomosed to the anterior urethra starting from 12 o'clock at the bladder.

Dr. Perikilis Koukourikis:

(silence)

Dr. Perikilis Koukourikis:

12 o'clock urethra and moving clockwise until the three o'clock. And this is an upside down anastomosis like a mirror image from the conventional approach.

Dr. Perikilis Koukourikis:

(silence)

Dr. Perikilis Koukourikis:

The traction and tightness of the anastomosis should be done with caution to not tear the urethra.

Dr. Perikilis Koukourikis:

(silence)

Dr. Perikilis Koukourikis:

A second needle is placed to start anastomosis again from the 11 o'clock at the bladder side. This is the same suture that we use before.

Dr. Perikilis Koukourikis:

(silence)

Dr. Perikilis Koukourikis:

Going to 12 o'clock urethra and moving backwards until the nine o'clock. We use the zero degree lens for the [half 00:33:58] of the procedure. We felt the need to change in 30 [ob 00:34:04] in the next step.

Dr. Perikilis Koukourikis:

(silence)

Dr. Perikilis Koukourikis:

When the half of the anastomosis is performed, the urethra catheter is inserted into the bladder, and the anastomosis is resumed. In order the two stitches to meet up at six o'clock.

Dr. Perikilis Koukourikis:

(silence)

Dr. Perikilis Koukourikis:

After the anastomosis is concluded, a new [inaudible 00:34:44] urethra catheter is placed and we don't use a suprapubic tube.

Dr. Perikilis Koukourikis:

(silence)

Dr. Perikilis Koukourikis:

The sutures are secured with Lapra-Ty at the bladder side and we usually pack the prostate bed with hemostatic agents. We put [Tisseel 00:35:22] and Surgicel at the neurovascular [inaudible 00:35:28] sites.

Dr. Perikilis Koukourikis:

(silence)

Dr. Perikilis Koukourikis:

And then, the peritoneal incision is closed with a continuous manner to extraperitonize again the site of surgery, to confine any possible urine leak, and [inaudible 00:35:50] any postoperative bleeding. So you can appreciate that by the end of the procedure, the prostate has been removed with minimal surgical trauma, and the pelvic anatomy has been well preserved.

Dr. Perikilis Koukourikis:

So we are talking for a true minimal invasive technique. This suture is also secured with Lapra-Ty, and a drain can be placed to the abdominal cavity. So this the conclusion of our surgery. Moving to the Yonsei experience, this is the last publication in the Journal of Urology, a propensity score matched analysis of 600 patients compared with 600 patients of retzius-sparing technique to the conventional technique, all performed by the same surgeon.

Dr. Perikilis Koukourikis:

In results, the mean operative time was shorter to the retzius-sparing group, and to the need for any additional reconstructive procedure was minimal. The positive surgical margin rate were comparable between the two approaches in T2 and also in T3, or more advanced disease, and the continence rate at six months were superior for the retzius group, 98% versus 77% in conventional group.

Dr. Perikilis Koukourikis:

I have to note, sorry about that, that retzius-sparing approach has been added recently to the EAU guidelines on prostate cancer as an approach offering improved early post-operative continence, and the same potential advantage as the open perineal approach, but without disturbance of the perineal musculature. As more and more urologists are doing this approach and adopting this approach around the world, we believe that retzius-sparing radical prostatectomy may be a candidate for future prostate cancer surgery with the advantages of minimal dissection and a standardized step-by-step surgical procedure following the anatomical plane.

Dr. Perikilis Koukourikis:

Thank you very much for your attention.

Dr. Jihad Kaouk:

Thank you so much Dr. Kourkourikis for your excellent presentation. That, again, raised a lot of questions that were addressed on the chat box and we thank the attendees that are active on writing their questions. We reach our third segment of our 60 minutes today, and this will be an open moderation where I will give the podium to our two esteemed moderators, Dr. Davis, and Dr. Peabody. Please mind also that the answers for the poll questions are out. If you want to touch on that during your discussion.

Dr. John Davis:

Thank you Jihad. Great session, both speakers. Jim, you may want to unmute, there you go. That was a dynamic chat box session, I've been typing feverishly for 40 minutes. You guys certainly stirred up a lot of interest in this.

Dr. John Davis:

So here's the poll question on the margins. Let people answer that. What I was just putting on the chat box at the end, I think... So why don't we just talk a little bit about margins, then talk about learning curve and continence, those are probably the big ones.

Dr. John Davis:

I think, my last comment, I think most... There are many series that have shown that positive margins when you look at T2 disease, you should be able to keep those less than 10%, and most of us kind of, I've looked at my data and it kind of goes up and down, and up and down, and as you experiment with available technique and varying degrees of high release, depending on your case selection, you might have little ebbs and flows of margins, so that's my personal challenge because I know mine are like you're seeing here where there in the teens, so the question is why are we getting a few extra margins that affects the percentages.

Dr. John Davis:

With T3, if you select a bad case and have pathologic bladder neck invasion, I think you have a little more risk there as well, so that's my only concern with doing retzius on every case, although again, when people really get their sample size up high enough, I've seen surgeons such as Bocciardi who can comfortably do a wider bladder neck margin and reconstruct it, but obviously you're sort of doing that blind. That was another good chat box question of do you see the ureters when you reconstruct, and I would suggest you don't want to see the ureters from posterior and if you did get that close, you may want to do a cysto.

Dr. John Davis:

You know, one interesting thing about all of this is this if very non-committal. I worked posteriorly for quite a while before I braved my way through a bladder neck. So can do a lot of the posterior planes, the nerve release, and if you don't like your bladder neck margin, or you see a ureter, you can always drop anterior and examine it and figure out if you need to stent, or do a more elaborate reconstruction.

Dr. John Davis:

Jim, you started ahead of me, so why don't we try to wrap up on the positive margin question and move onto the other two.

Dr. James Peabody:

I think it's similar to what happened when we started doing robotic prostatectomy, you wanted to start with cases that were favorable, so don't pick somebody with a PSA of 40, and big nodule that you're worried about. If you have an MRI, look at that. Try to operate on somebody who's pretty likely to have organ confined disease that will get you more confidence because you'll be able to do the cases successfully.

Dr. James Peabody:

I think anterior tumors are a little bit trickier. One of the questions in the chat box said that the pathologist at that institution was calling more margins anteriorly and the surgeon thought it was just because there wasn't as much tissue. I think that may be part of it. We are trying to stay below the plane that we typically would take anteriorly, so if you have a big anterior tumor and you aren't experienced, probably don't start there.

Dr. James Peabody:

The original description of the technique for laparoscopic prostatectomy from [Losari 00:43:05] was to go posteriorly with seminal vesicles. They stopped after getting the seminal vesicles, and what John said is absolutely right, you can incrementally move forward on this until you get to the point where you've removed the prostate and then even, the anastomosis is tricky. In the beginning it's disorienting and can be frustrating, especially if the bladder neck tips forward a little bit because it's hard to see that, but once you get it started, it really is pretty easy, you just have to get your head wrapped around how to do it backwards from the way you used to do it.

Dr. John Davis:

Yeah, and I think, I put it in the chat box too, my favorite videos that are on YouTube, so everyone can get to them easily, are from the challenges in laparoscopy course and on one version, it's Bocciardi case, and he really has a nice way of explaining how you essentially lift the bladder off of the prostate and the cautery just kind of weakens the tissue and it kind of sequentially shows you the right plane. Especially as you work, as Dr. Madi showed, working around the sides quite a bit.

Dr. John Davis:

And then the other video is just, I mean, they're all just personality issues, or preferences, Dr. Rha's video from the same course, it might be a year later, he kind of slows down and really explains how to mirror image the anastomosis, especially once you recognize where the anterior wall is, you can get your anchoring four stitches down there, it looks like there's a long way to go, but it'll reach, and then it's just a matter of reversing field, and that was a good chat box question. I think 30 ob is useful, especially if you're learning, but if you've got marionette strings, or just a really thin easy exposure, there's nothing wrong with staying on zero. You may have to be sort of reaching and pulling the bladder down from the ceiling to see, but it's there.

Dr. James Peabody:

John, have you had problems with patients with narrow, fatty pelves that it's hard to get down where you've planned to go posterior and congruentive to anterior? And I guess for the surgeons as well, Dr. Kaouk, also, is this something that's happened to you, or have you always been able to kind of soldier on and get the case done?

Dr. John Davis:

I'll just comment that if that is the case, you usually figure it out early. Like, at the SV step you can already tell this is going to be a [inaudible 00:45:37] maybe punt and move on. I can't recall working way into the case and then giving up on it. [crosstalk 00:45:45]

Dr. James Peabody:

Right, it usually is [crosstalk 00:45:48] look into the pelvis.

Dr. John Davis:

Have you guys had that experience?

Dr. Jihad Kaouk:

I don't do retzius-sparing myself, but I'm trying to compare that to the perineal approach that I do because the view at the anterior dissection of the apex and the urethra and the anastomosis is identical. If you would not see how I started and just get to look at the anastomosis, you cannot tell if it is a retzius-sparing or a perineal approach, very similar. The fat and the patient weight is not a factor at all in the perineal, but what I find the two factors are, one is definitely the size of the prostate, so 80 grams and above become extremely difficult to do perineally, and the second is a little bit of radiation of the pubic [inaudible 00:46:38], so that V shaped angle, as it gets too narrow can clinch my instruments and limit my movement.

Dr. John Davis:

So I had one theory on continence that I'm curious if Jim and or other panelists want to weigh in on. If you do the cystogram on a patient, I don't always do cystograms, but I've done it on the salvages because I'm always more worried about them, so then you get that nice sagittal lateral view of your reconstructed work, the retzius is impressive in that the urethra just kind of come down and just has a nice anterior angle, and when you stare at that, it's always made me wonder if the bladder is hanging from its natural retzius attachments, maybe as it fills, it just is filling at a low pressure from top to bottom whereas at the end of an anterior case, when we drop the bladder and it's resting on the rectum, basically, now urine has to fill against gravity, or the weight of the bladder from bottom up. Who knows? Jim mentioned about a urodynamics study idea, you wonder if a filling pressure would enlighten us better on why either retzius, or all the variations people have described that preserve bladder angle might-

Dr. James Peabody:

Yeah, I think we don't know. There are some papers from years ago looking at cystograms and the position of the bladder on an AP cystogram when the bladder base was above the top of the pubic bone, the return of continence was much better than it had drifted down further, and when the bladder neck was well below the pubic symphysis, the continence rates were worse, so I don't know if that's part of what is happening. I think this is, it'd be an interesting question to get a better answer to, I think.

Dr. Rabii Madi:

Yeah, I would have to agree with that if I can just step in here. I think, as you know, the mechanism of continence is really multifactorial and there are different elements included in it, but I think the key is the minimal disturbance you do to the urethral attachment and anchoring, the better the outcome's supposed to be, and that's, I think, the retzius-sparing what offers, the bladder neck factor, maybe because again, the bladder neck is not totally untouched, so... And the bladder neck preservation is far higher, it's like 90% versus 60 or 70 percent in the regular way, so it could be multifactorial.

Dr. Rabii Madi:

I think it's hard really to pinpoint exactly what the reason is, but yeah... I don't know what study we need, to be frank with you, to find that.

Dr. Jihad Kaouk:

You know, definitely, it's so apparent that the time to continence is effected and shortened significantly by the retzius-sparing and by the perineal approaches, open or robotic, but the absolute continence, the time at long-term, for the percentage of people who become totally continent, that is something that's still unclear and the results are variable, I think.

Dr. John Davis:

So Perikilis, very nice talk for Dr. Rha. You can't answer my question because I've already been to your hospital and I know what it is, but for Rabii, or other, and Jim, what do you think about the efficiency of this operation once you get through the learning curve? You can list on a slide multiple parts that you don't have to do posterior that you do anterior. I say this because Rha did a case, I happened to be visiting with a separate meeting and it was for the WRSE, right? The World 24 hour global one and they had me introduce the case, so I had my back turned to the screen, I was looking at a laptop going over the case, and all the details, answering a few questions, then I turn around to go back to the case and Rha's on the urethra already, it's ridiculously fast.

Dr. Perikilis Koukourikis:

Yes.

Dr. Rabii Madi:

I think can be really very fast on the retzius-sparing. Now, you spend more time maybe dissecting the pedicles initially, but once you have that pedicle dissected and then it goes much smoother and faster, and you save on some steps. You don't drop the bladder, this might take 10, 15 minutes to do. So you save on some steps and you take more time, but overall, at least in my hand, the retzius-sparing has shorter robotic console time and operative time, even the salvage one. So you can be really fast. The fastest I think I remember, I got 52 minutes for the retzius-sparing.

Dr. James Peabody:

I think it's, in the beginning, when you don't know what you're looking at, which is what the problem is, you don't understand the anatomy, you're not sure where to put the instrument, how to access the plane, it's going to take longer. Once you get comfortable with that though, it think you can go faster.

Dr. Perikilis Koukourikis:

Yes, I'd have to say that our median console time is about 40 to 50 minutes, in Professor Rha's hands.

Dr. Jihad Kaouk:

That's pretty impressive. How about the hospital stay, pain management post-op?

Dr. Perikilis Koukourikis:

The Korean is a little different, the health system, so the patient stays a little more. It's about three to five days.

Dr. Jihad Kaouk:

Yeah, that's a different set up and expectations. How about Dr. Madi here in Georgia?

Dr. Perikilis Koukourikis:

Me, they go home the next day. It's median hospital stay is one day for both groups.

Dr. John Davis:

And Rabii, one of the questions in the chat box was, actually somebody put it in the Q&A, but I think I moved it over, they wanted to know about doing a lymph node dissection after you've done a retzius. Obviously that's not through that same pouch of Douglas incision. I just make a generous peritoneal... It's a very cephalo-type approach, but can you make a comment about how to expose the nodes, and also preserve your hard earn worked on the true retzius anterior?

Dr. Rabii Madi:

Yes. Actually, I have that video on the salvage prostatectomy, but tried not to show it because of sake of the time. Yes, you can do definitely. The landmark I use is the vas deferens laterally, and the obliterated umbilical ligament medially, and I made that incision here, and then by incising that, you will find the external iliac vein, and you can do some lateral dissection there and without dropping bladder. You don't have really, it's just limited, and if you want to extend it or go deeper into the internal iliac artery, you can do that. If you go to the external iliac, you can do it.

Dr. Rabii Madi:

So you leave most of that attachment anteriorly all free, but you can definitely do any type of lymph node dissection, no problem with that.

Dr. John Davis:

Good points. So we've talked a little bit about continence and margins. Maybe a few more about learning curve. Again, Jim you've done it, I know you did it at the initial [inaudible 00:53:53] meeting, so that's four years ago. And there were questions in the chat box about how to get residents involved as well. What are you all's thoughts on training yourself as well as resident fellows?

Dr. James Peabody:

I think as the senior surgeon, you have to be comfortable enough to do the whole case yourself, and then with training you have to be comfortable enough to anticipate the problem that the resident may be about to get into and intervene before that happens, and then be able to take over and fix whatever problem might be caused, and it takes a while to do that, I think.

Dr. James Peabody:

Our residents are trying to learn the anterior approach and trying to the learn the posterior approach, that adds and extra layer of complexity, I think, and the truth of the matter is that our residents do more anterior approaches than they do posterior approaches. There are some who are exceptionally good who move up to that level, some of the fellow. I think that, John, you had alluded to that in one of your comments.

Dr. James Peabody:

It's a little bit higher skill set, I think. Although, we have had some resident who in the end felt like they liked the posterior approach better. I don't know of many of our residents who are doing it routinely in practice.

Dr. John Davis:

Got you. We had one fellow that had practiced in the military for a few years and then came back, so it was sort of an unusually experienced fellow, quasi-attending, and he got it. For the rest, they can certainly practice up their posterior SVs, and for most of them, if they expose it right, the initial pedicle dissection is r the same look, so they can move there, and then I think my next goal will be to get them sewing upside down. I think it'll take me a while how to train bladder neck because I'm still... To me, that's still an adventure every time I do it.

Dr. James Peabody:

Yeah. Yeah, I start a lot of them and then let them finish, but the start seems to be the key part to get that anterior bit well closed.

Dr. John Davis:

Well, Jihad, I'm looking at the clock, we're down to like a minute, so as our host, maybe you want to give some wrap up comments so we can finish on time.

Dr. Jihad Kaouk:

Yes. I would like to ask the surgeon presenters first if they have any final comments before we wrap it up.

Dr. Rabii Madi:

I think I would definitely encourage urologists who are doing robotic prostatectomy to give it a try. As I mentioned before, it's always reversible. So if you are struggling at any part of the case, you can always go back, and I strongly believe that the continence is better earlier, maybe even long-term. The salvage one is definitely far better in terms of continence. We are going to publish that data soon, so hopefully we'll have it accepted soon.

Dr. Jihad Kaouk:

Thank you so much. Dr. Koukourikis?

Dr. Perikilis Koukourikis:

I'd have to say that we are waiting for more data to have a stronger position for the retzius-sparing approach to be the... Every surgeon could adopt it.

Dr. Jihad Kaouk:

You know, within the last few seconds here, I really want to thank you all, especially the fantastic presentations and the moderation that was provided by Dr. Davis and Dr. Peabody. We learned a lot from all of you today. I want to give one big shout out to Michelle Paoli who really is behind the scene putting all the series together, and to my co-editor of the series, Dr. Dr. Chandru Sundaram. So thank you all for joining today. This was a very exciting session. Thank you for your contribution, and we look forward to having you on future sessions as this is a bi-monthly series by the endourology society. Thank you and have a wonderful weekend everyone.