Dr. Ash Tewari | Prostate Cancer Center NYC

ROBOTIC PROSTATE CANCER SURGERY

ART (TM) stands for Advanced, Athermal, Anatomic, Robotic Technique. ART 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.

The ART 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.

The ART 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.

ART 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.

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 ART 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, ART 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 aimed at describing the ART approach, and is not meant to present ART 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.


ART AND SEXUAL FUNCTION

Dr. Tewari and his team of clinicians and researchers have won awards from his fellow urologists for advancing the field of nerve-sparing prostate surgery.

Dr. Tewari's technique is unique. First, he and his team carry out preoperative imaging, such as ultrasound and magnetic resonance imaging (MRI), to determine exactly where the cancer is located and where the nerve bundles are, so they will know prior to surgery where they are looking and what to expect. This also gives Dr. Tewari a better idea of how early or extensive the cancer may be and how to discuss the likely results of the operation with you. Because Dr. Tewari and his team are experts in the anatomy of the prostate and the regions around it, they know where the delicate bundles of nerves that are responsible for the bladder and bladder sphincter function (the circular muscle around the neck of the bladder that allows you to control urination) and for controlling penile erection are likely to be found. During surgery, particularly in cases of early cancer that has not spread beyond the prostate gland itself, Dr. Tewari and his team very delicately remove the cancerous prostate gland while avoiding damage to as many of these bundles of nerves as possible. Rather than using cauterizing techniques that can damage nerves through heat, they use an "athermal" approach that does not heat the tissue. All of the steps Dr. Tewari and his team take to make sure nerves are spared contribute to the superior outcome in ARTTM that have set the standard for prostate cancer surgery and lead to nerve-sparing results.


ART AND URINARY CONTROL

A concern that many men understandably share in considering prostate surgery is what effect it will have on their bladder control. A major advantageof having robotic prostatectomy at Mount Sinai is that the procedure is performed by Ashutosh (Ash) K. Tewari, MD, Chairman of the Department of Urology. One of the world's foremost leaders and innovators in robotic prostate surgery and prostate cancer research, Dr. Tewari has performed more than 5,500 robotic prostate cancer surgeries in the past decade.

The Advanced Robotic Technique (ARTTM) used for prostatectomy, and standardized by Dr. Tewari, utilizes an anatomic approach to surgery that does not involve the use of any thermal (heat) energy that could damage important nerves that control urinary and sexual functioning.

When the prostate gland is removed in a robotic prostatectomy, damage can occur to the urinary sphincter, the circular muscle at the base of the bladder, resulting in temporary or permanent incontinence. Good urinary continence outcome sare determined by the surgeon's ability to preserve and restore the male pelvic anatomy, including the urinary sphincter muscle, in such a way that it is unaffected by prostate removal. Dr. Tewari has standardized a unique procedure that restores the urinary control muscles following prostate removal. This procedure allows for more rapid recovery of continence compared to other surgical methods.

Dr. Tewari's unique technique to preserve continence has gone through several generations of innovations over standard robotic prostatectomy. Each one of these modifications has helped more and more of his patients to ultimately not leak urine or stop urinary leakage sooner after surgery. When you operate on thousands of patients, even a very small percentage of patients becomes a sizable number that could serve as cases to look back on, learn from, and use to lead to new innovations in urinary continence maintenance after surgery. One inherent challenge with prostate cancer surgery is that even with the best preservation of nerves and the sphincter, the prostate still has to be removed. What if in certain people, the prostate gland contributes to continence, and once it's gone, incontinence occurs? How does the surgeon address this challenge? These prostate-dependent cases could contribute to some of the surprise incontinence that can occur even in the best surgical cases with the best surgeon. This small percentage of patients ultimately require surgical correction to preserve continence. To address this challenge, Dr. Tewari's ARTTM technique not only preserves the nerves, sphincters and supporting tissues, but also accounts for the tissue that is lost. Beginning in July 2012, Dr. Tewari added construction of a muscular tube that replaces the gap left by the prostate and also serves as a dynamic muscular sling that provides extra safety at times of stress. This technique, pioneered by Dr. Tewari, has given his patients earlier and better continence.

Urinary control is compromised following any surgical treatment of prostate cancer. Our approach for reducing the rate of incontinence following robotic prostatectomy is rather straightforward. We had identified and studied which of the several supporting structures contribute toward the perfect functioning of urinary control muscles; the sphincter. We also recognized that (at least visually) the entire sphincter area looked quite different than what it was prior to the surgery. Not just for the missing prostate but also because the supporting structures were either removed or were disorganized during removal of the prostate. We address the incontinence issue created by the surgery by reconstituting the support anatomy, carefully putting it all back together. We refer to this approach as the Total Reconstruction Technique and the resultant outcomes are impressive. 97 percent of these patients are continent after surgery.

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