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Art or Robotic Prostate Cancer Surgery


ARTTM (Advanced, Athermal, Anatomic, Robotic Technique) of prostatectomy is a novel and precise technique developed by Dr. Ash Tewari who has been doing this procedure for over a decade and has personally performed several thousands of these operations.

Dr. Tewari is one of the few surgeons who are considered pioneers of this operation, and has won several awards for his technique.

ARTTM technique is based on individual patients' anatomy. It is precise in nerve sparing, incorporates a hammock concept of the nerves found around the prostate, is athermal which ensures that the nerves are not damaged by heat, and is traction free which reduces the physical trauma on these delicate nerves. Through these aspects, this technique aims to reduce the severity of urinary incontinence after surgery.

ARTTM technique also maximizes urinary control recovery. Basically, this technique has very high probability of not leaking urine.

Furthermore, promoting its success, the ARTTM technique incorporates pre-operative MRI based planning for cancer removal and Intraoperative NeuroSAFETM protocol in which the entire nerve margin is evaluated by the pathologist in real time so that more nerves could be saved, yet giving us the ability to ensure any extra cancer is seen before finishing the operation. MRI guided NeuroSAFETM technique was developed with guidance and in collaboration with the University of Hamburg.

The benefits include:
  • High rates of early post surgical continence.
  • High rates of sexual function recovery.
  • Minimization of blood loss during surgery.
  • Avoidance of thermal cauterization to control bleeding during nerve sparing surgery and thus better preserve nerve health.
  • Minimized post-surgical pain.
  • Minimal post-surgical hospitalization.

ARTTM is not just an acronym. It is a carefully thought through approach using robotic prostatectomy to treat prostate cancer patients. An integral part of this approach is to visualize the nerves around the prostate as a hammock of delicate fibers on which the prostate is resting. This is the trizonal neural architecture.

Prostatectomy is performed through small dime-sized incisions in the abdomen.

The Trizonal Neural Anatomy a) Proximal Plate b) Predominant Bundle c) Accessory Pathways and the neural hammock.

Accessory pathways

Lateral pelvic fascia left intact

Lateral pelvic fascia reflected

The Neurovascular Bundle

The nerves travel within layers of the fascia which is just 1-2mm thick

The Neurovascular Plexus showing the trizonal hammock

The Neurovascular Plexus showing the trizonal hammock

This technique attempts to save every possible nerve fiber, including accessory nerves. The nerves behind the prostate are often ignored and can be damaged. This calibrated approach is aimed at achieving a fine balance between the competing goals of cancer eradication, urinary control and recovery of sexual function in patients undergoing prostatectomy. ARTTM is a technique which has been refined through in-depth studies of periprostatic anatomy, from fresh human specimens, correlated with 3-D magnified video footage of many of my thousands of surgical cases.

The ARTTM procedure involves meticulous dissection of the prostate and as a key element, absolutely avoids electrical cautery during the nerve release process, in a completely athermal way. Current technique is founded on a summation of thoughts, concepts, anatomic findings, surgical steps and reconstructive efforts, all aimed at eradicating the cancer and at the same time, save nerves around the prostate during robotic prostatectomy. It is important to reflect on the evolution of the nerve sparing procedure which was pioneered by Dr. Patrick Wash from John Hopkins. Prior to his work no one knew about these important erectile nerves. The field of robotic surgery actually looks over the shoulders of these giants who initiated, developed and refined nerve sparing techniques which all surgeons use today.

Recently ARTTM has incorporated a novel reconstructive approach to minimize and prevent urinary leakage in what we refer to as the Total Anatomic Reconstruction Technique.

Please bear in mind that the above description is just aimed at describing the ART approach. It is not my intention here to present it as a better technique than what is used by other surgeons. To be candid, with all our best intentions, skill and experience our approach does not work for every patient, highlighting the fact that we have lot more progress to make.


Revelation 1. How Many Nerve Bundles Are Responsible for Sexual Function and Urinary Continence?

Recently, many researchers and Dr. Tewari have found that there are multiple branches of sexual nerves that surround the prostate gland. These nerves exist in a hammock network on which the prostate resides. ARTTM technique not only saves the conventional bundles of nerves, but also saves the remaining nerve branches of the hammock. These anatomic findings - one of the "A's" in ART - are integral to the ART technique developed and pioneered by Dr. Tewari.

Revelation 2. Nerves don't handle heat very well.

They actually disintegrate later and function is lost. Dr. Tewari revisited this fact and performed temperature monitoring during the surgery. This contributed to pioneering work on Athermal-nerve-sparing technique. Athermal is the second "A" of the"ART" technique. The cold cutting technique now is considered to be the standard of care.

Revelation 3. You need touch to preserve nerves.

Well, not exactly. You need magnification, visual cues and microscopy during the surgery to preserve the nerves. Nerve sparing is an art and a skill; it is more dependent on the surgeon rather than on the surgical approach used.

Revelation 4. Nerves could either be saved or not saved in surgery - only two outcomes, there is no in between!

Dr. Tewari's group were among the pioneers who studied the risk of cancer escaping outside the capsule (the boundaries of the prostate). They realized that even in cases where the cancer is slowly creeping outside the prostate gland, not all nerves are actually involved in the cancer. What was needed was high-definition imaging to identify the uninvolved nerves, use of microscopy during surgery, and redefinition of anatomical planes and tissue surrounding the nerves. To do this, Dr. Tewari's group performed detailed and meticulous anatomical studies of human cadavers and developed a system of Risk Stratified Anatomical Grades of nerve sparing that, along with use of imagery, has become an integral part of the ARTTM Procedure. Essentially, by using this approach, many patients who earlier could not be considered as candidates for nerve sparing could have partial or near-total incremental nerve sparing.

Revelation 5. The old surgical professors were right. Handling tissue is an art.

We can enhance the precision and delicateness of nerve sparing by getting feedback from the nerves. If you pull them too hard, they first will cry and then will die. We were the first to use intraoperative feedback to avoid nerve damage, and thus we helped in developing the "Traction-Free Nerve-Sparing" technique that is now part of the ART procedure.

Revelation 6. What happens to the orgasm after prostate cancer surgery?

Yes, we have studied this important function and we believe that while erection and orgasm are controlled by different sets of nerves, our expanded nerve-sparing technique actually saves nerves needed for erection and orgasm.

Revelation 7. Preoperative planning helps.

Using pre-operative magnetic resonance imaging (MRI) to aid in decision-making and fine-tuning a nerve-sparing technique helps Dr. Tewari individualize the surgery and not use a one-size-fits-all approach. A surgical technique that is measured and planned for a unique individual is likely to have a better outcome than one that treats every anatomy as the same! Dr. Tewari has debated his position-in favor of use of imaging-in front of thousands of leading urologists and is a believer in planning MRI.

Revelation 8. Do these revelations actually change the outcome?

The answer is yes! Based on literature published by various programs, the ART procedure has one of the lowest risks for leaving residual cancer and one of the highest probabilities for achieving continence and sexual function, while ensuring that all of the cancer is gone. Simply put, our program has one of the highest batting averages

We truly believe that cancer treatment is a journey and not a destination. While we have thousands of patients who have done very well, we also have a small percentage in whom we did not achieve an ideal outcome, as a result of their cancer being more aggressive or having adverse anatomical structuring that we were faced with. We remember these patients more than our successful and happy patients. Most of our innovations have emerged because of our efforts to minimize the side effects of erectile dysfunction and urinary incontinence. We owe our innovations to our patients, who give us feedback and sometimes suggestions for changes in our procedures. We believe that our results stem from our team members' and researchers' commitment and learning mindsets. They have contributed to the learning culture that is a hallmark of our program.


There are multiple nerves around the prostate. The prostate gland is surrounded by a capsule and many thin layers of fascia containing fat, blood vessels, nerves and the cross communicating ganglions coordinating erection and orgasm. Within the capsule is the cancer, which is slowly eating through the capsule and trying to escape outside, sometimes using nerves as its route of escape. The capsule is thinner than an orange peel and the surrounding fascia is like the outer layers of an onion. Nerves are off white in color with a width of just a couple of hairs. Throw in some fat, blood and inflammation in the mix and you have a quite complicated task of separating nerves from cancer in literally microscopic dimensions.

That is why the success of this operation is judged not just by what is removed, namely the cancer, but also by what is left functioning, such as the nerves for sexual function and sphincter for urinary control.

Therefore we attempt to preserve every nerve fiber and not just neurovascular bundles, which may or may not contain crucial cavernous nerves and which may be a little farther afield from the bundles (tri-zonal picture). Another benefit of our approach is that we work hard at not damaging the relay center made up of ganglions and nerve fibers which coordinates the fine balance between erection, orgasm and bladder function.

Q. How do you execute your technique?

A. Our goal is minimal disruption to the periprostatic tissue in which the nerves are traveling to the prostate from the mid line and working our way around just on the surface of the prostatic capsule. We accomplish this through our extensive understanding of the areas anatomy and meticulous planning of each case and approach utilizing our experience gained through thousands of surgeries and by controlling bleeding from the small blood vessels as they enter the prostate individually. We are also inherently aware of the delicate nature of the tiny structures involved that do not handle heat, traction or manipulation well, and work to best ensure that these structures remain undamaged during the surgical process.

Q. Surgeons speak about sparing the nerves on one side of the prostate, away from the cancer, but is it possible to save some of the nerves on the side that is involved with the cancer?

A. We studied periprostatic neuroanatomy and noted that these nerves travel in a millimeter thick tissue (lateral prostatic fascia). We found that this narrow space containing nerves could be sub-divided into very tiny inner and outer compartments. Now, mindful of the risk of cancer eroding through the capsule (extra prostatic extension), we are able to separate the nerves in either the inner or outer compartments so that removal of these nerves, if required for cancer control, is not an all-or-nothing deal. This lowers the risk for a positive surgical margin (residual cancer around the nerves) while saving the nerves which could safely be saved.


"Cancer control" refers to the ability of the surgeon to remove all of the cancerous tissue from the affected organ and potentially from the body . This is measured by surgical margins (the rim or border of the tissue removed in cancer surgery). Over the course of several thousand robotic radical prostatectomy surgeries, Dr. Tewari has achieved full cancer control in over 90% of his patients who had localized prostate cancer (cancer confined to the prostate gland). These results are amongst the best in the class.

He has great skill in operating on patients with more-aggressive cancers and has established on of the most innovative, imaging and genomic based active surveillance program which avoids surgery in many patients with indolent cancer and selects aggressive cancers for treatment. This translates to a greater than 95 percent, 10-year cancer-specific survival rate in select patients.


Q. In sum, what do you attribute these results to?

A. I think that a number of factors have amalgamated to produce these results. I believe that experience with thousands of cases gave us very high proficiency in the precise identification of tissue planes, a highly tuned appreciation of periprostatic anatomy and proficiency in risk grouping of patients for various grades of nerve sparing. Additionally, utilizing high resolution 3-Tesla Endo Rectal MRI and liberal utilization of tissue microscopy during surgery, all have contributed towards our oncological optimization approach and have given us comparable margin rates at the postero-lateral aspect of prostate.

Q. Can you tell us about re-admission rates following ARTTM?

A. The readmission rates following ART are 2.6%. The distribution of these complications according to Clavien-Dindo is as follows :
Grade 1 - 0.3%
Grade 2 - 0.3%
Grade 3 - 1.5%
Grade 4 - 0.5%

Q. How would you compare ARTTM results with other prostate cancer treatment modalities?

A. True scientific comparison of outcomes do not exist because the different modalities have not been compared in a prospective randomized manner to date. Therefore, we have attempted to analyze existing clinical treatment data to provide some indicators which may be helpful. The data has been extracted from previously published large center studies and weighs them according to the numbers of patients in each series. It is summarized in a recent publication.

Q. How does this translate for the physician seeking to recommend the best treatment for his patient or for the patient trying to make his own treatment choice?

A. The point is this. No randomized trial exists that takes into account every factor and every criteria of even the major treatment modalities, never mind some of the less utilized treatments. The many studies that are done tend to be narrowly focused on one or two outcome criteria and tend to use different patient cohorts. While of interest to the researcher and to the practitioner, they are of lesser direct utility to the end user; the cancer patient.

For the patient, his concerns are broader and more immediately practical. For example, no patient will make a treatment decision based solely on whether a given treatment produces lower stricture rates in a cohort of Medicare patients. His concerns are broad; will his cancer be completely removed? Will it come back? How will he recover from the surgery? Will he be incontinent? What will be the degree of his sexual function after surgery?

Even with experience, I personally have patients who never regained sexual function, or are incontinent or had positive margins. Surgical complications are also a possibility with this surgery, as they are of any other type of surgery. This particular field of surgery is quite humbling and I really think that we have much more to learn in order to help our patients.

Patients will also look for surgeons with experience, the more experienced the better, because ultimately experienced surgeons tend to have better results. Patients will also look for a well equipped facility with an excellent reputation. I believe that here at our center or prostate cancer we provide the patients with both the best patient care through the experience of our surgeons and the world class nature of our facilities.

I hope I've been able to give you a fair sense of our approach to prostate cancer treatment and to the thinking behind our techniques. While we have some ways to go in our quest toward ideal results, today there are excellent ways of treating prostate cancer and there are many well qualified practitioners.

Good luck with your decision-making and your treatment.

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