Expertise in open, laparoscopic and robotic-assisted laparoscopic modalities led one prostate surgeon to develop the revolutionary SMART prostatectomy, which reduces operative times and postoperative complication rates. Now, he offers this innovative procedure to patients from across the globe in a customized unit at Lenox Hill Hospital.
The Samadi Modified Advanced Robotic Technique (SMART) combines best-practice open surgical prostatectomy techniques with oncologic insight and perspective gained from extensive training on robotic surgical platforms. David B. Samadi, MD, Chair of Urology and Chief of Robotic Surgery at Lenox Hill Hospital, and Professor of Urology at Hofstra North Shore-LIJ School of Medicine, pioneered the approach.
As the next step in the evolution of minimally invasive surgery, the SMART prostatectomy further refines the laparoscopic approach that replaced traditional open surgery as the standard of care for surgically resectable prostate cancer.
“As an oncologist with years of open and laparoscopic surgical experience, I’ve combined the capability to recognize whether cancer is outside the prostate or not and developed a nerve-sparing surgery for optimal outcomes. It’s like a high-rise building: The foundation is the oncological expertise, and the building itself is the laparoscopic skill. The penthouse is robot-assisted laparoscopic experience — the robotic surgical platform can’t stand alone without that foundation.”
— David B. Samadi, MD, Chair of Urology and Chief of Robotic Surgery at Lenox Hill Hospital; Professor of Urology at Hofstra North Shore-LIJ School of Medicine
The robot’s tactile feedback affords an experienced surgeon the opportunity to successfully perform prostate removal while preserving continence and potency.
While laparoscopic prostatectomy significantly reduces blood loss, surgical trauma and other comorbidities associated with open surgery, the technique requires surgeons to labor over the operating table for several hours, manipulating rigid instruments that do not always move intuitively.
Prostate cancer is difficult to treat using any modality because of the gland’s deep location in the pelvis below the pubic bone. The challenge is compounded by the prostate’s proximity to the rectum, urethra, major blood vessels and nerves responsible for continence and sexual function.
The da Vinci Surgical System resolves many of these issues by improving visualization of the surgical site and offering surgeons wristed instrumentation that allows greater mobility. Additionally, instead of hunching over an operating table, surgeons sit at an ergonomic console, where they control the platform’s instruments.
David B. Samadi, MD, sits at the surgical console, where he will perform robotic prostatectomy from start to finish.
Dr. Samadi combines oncologic expertise with years of experience cultivated in each modality for radical prostatectomy to identify subtleties in each case few surgeons could pinpoint on their own.
“My laparoscopic training strengthens every surgical procedure I perform,” he says. “But the key to the program’s success is that I also have extensive training in robotic surgical platforms and oncology. Knowledge of prostate cancer has changed dramatically in the past decades, and my job as an oncologist is to present patients with the latest research and offer them guidance to make the right treatment decision for themselves.”
The Genesis of an Idea
During robotic prostatectomy training, Dr. Samadi learned the nuances of radical prostatectomy, including the conventional approach that emphasized opening the side of the prostate and suturing the dorsal vein complex. These procedural protocols were widely believed to prevent potentially catastrophic complications. SMART prostatectomy utilizes a different approach and does not require suturing the dorsal vein complex until the end of the procedure.
Like many innovations, the idea for the SMART approach was conceived in a serendipitous moment and developed over a long period of hard work.
“When learning open surgical techniques for prostate removal, surgeons are taught to place the suture in the dorsal vein to prevent massive blood loss,” Dr. Samadi says. “During one prostatectomy, I didn’t place the suture, but there was no bleeding. Realizing that this didn’t result in excessive blood loss, I thought about different approaches to prostatectomy. To reduce damage to the anatomy, perhaps we don’t have to open the side of the prostate at all.”
Just as an athlete studies game tapes, Dr. Samadi analyzed hours of prostatectomies — thousands of procedures — he had performed to identify an alternative approach and technique to improve upon traditional robot-assisted laparoscopic prostatectomy.
“A simple modification to the conventional procedure — not opening the side of the prostate and waiting to suture the dorsal vein later in the procedure — allowed me to leave neurovascular bundles in place and avoid damage caused by cautery instruments,” he says. “This changed the way I looked at prostatectomy. Instead of moving neurovascular bundles away from the prostate, I could move the prostate away from the nerves and cause less damage.”
Turning the Procedure Inside Out
Prostatectomy requires a high degree of dexterity to reach the gland and meticulously separate it from surrounding critical structures.
“During prostatectomy, surgeons peel the nerves responsible for sexual function and continence away from the prostate to remove the gland,” Dr. Samadi says. “But the less we do to the nerves, the less risk for complications there will be.”
The SMART technique mitigates complication rates by inverting the process.
“I approach from above the prostate and remove the gland without disrupting the nerves encapsulating it,” Dr. Samadi explains. “Whereas conventional laparoscopic prostatectomy utilizes an outside–in approach, SMART prostatectomy uses an inside–out methodology, avoiding damage to surrounding nerves and tissues. This is how I achieve 96 percent continence and approximately 80 percent preserved sexual function rates.”
These rates were documented in the July 2010 issue of the Journal of Endourology, in an article comparing the SMART technique with procedures that included the dorsal venous complex suture. The article also noted that “increased experience with robot-assisted prostatectomy resulted in improvements in oncologic and functional outcomes.”
Through six small keyhole incisions, Dr. Samadi introduces da Vinci instrumentation to the surgical site. After bilaterally incising the median umbilical ligament to the vasa deferentia and bringing down the bladder, he reaches the retropubic space, where he exposes the prostate and severs the gland’s connection with the bladder.
Dr. Samadi cross-clamps and cuts both vasa deferentia to facilitate dissection of the seminal vesicles — components of the neurovascular bundles. To spare the nerves, Dr. Samadi rotates the seminal vesicles away from the prostate’s surface, minimizing traction on the neurovascular bundles. After this step, Dr. Samadi uses blunt dissection with curved instrumentation designed for the da Vinci Surgical System, alleviating the need for cautery devices.
With critical structures no longer obstructing access to the prostate, Dr. Samadi removes the gland from the urethra and rejoins the neck of the bladder to the urethra.
Built for Precision and Speed
SMART prostatectomy reduces operative time to approximately one to one-and-a-half hours and does not require blood transfusion. In the nearly 6,000 SMART prostatectomies Dr. Samadi has performed, his patients have never suffered complications, such as rectal perforation or reoperations, associated with laparoscopic approaches.
SMART technique, defining the surgical pathway for better outcomes
Dr. Samadi’s prolonged success is partly due to the fact that he performs each procedure himself, using the same dedicated operating room team and no trainees.
“The best place to teach residents and fellows is in simulation labs,” he says. “Just as pilots don’t get in a plane carrying 500 passengers, surgeons shouldn’t be thrown into the operating room and told to go practice on people. Patients should be protected from such situations. They have only one sex life, and nerve damage and continence issues heavily impact their quality of life. To get the best outcomes, the most skilled surgeon should lead in the operating room.”
On the Front Lines
Dr. Samadi’s oncology training gives him a unique perspective, a mental tumor board continuously deliberating over treatment options. He recognizes the value of multimodal therapies for later-stage cancers and notes that surgery is the best option for early-stage, localized prostate cancer.
When open surgery held greater prominence in prostatectomy methodology, radiation was a popular frontline alternative for indicated cases. However, radiotherapy has been consistently shown to produce more complications than does surgery, most comprehensively documented in the February 2014 Lancet article “Incidence of Complications Other Than Urinary Incontinence or Erectile Dysfunction after Radical Prostatectomy or Radiotherapy for Prostate Cancer: A Population-based Cohort Study.” These include severe rectal toxicity and related bowel injuries, second cancers arising in the gastrointestinal tract due to treatment (309 cases per 100,000 person-years), and, most commonly, urinary obstruction. Even stereotactic body radiation therapy, or CyberKnife, which delivers stronger, more localized doses than standard intensity-modulated radiotherapy, leaves approximately 44 percent of patients with genitourinary toxicity two years after therapy. The study was published in The Lancet Oncology (2014; 15:223-31).
“Radiotherapy and high-intensity, focused ultrasound bank on random biopsy, which is not always accurate,” Dr. Samadi explains. “Surgery, on the other hand, provides accurate staging — you know exactly how much cancer is present, where it’s located and whether it’s spread to the seminal vesicles and lymph nodes.”
Additionally, prostate-specific antigen (PSA) levels can fluctuate up to two years following radiotherapy, which can traumatize people who think their cancer is recurring. PSA levels remain constant following prostatectomy, reducing patient anxiety.
Frontline surgery also leaves treatment options open for the future.
“If cancer returns after surgery, we can always provide radiotherapy,” Dr. Samadi says. “But, if radiotherapy fails, surgery would be extremely challenging, if it’s even possible.”
Moving a Program
The cornerstone of Dr. Samadi’s patient care model is compassion.
Dr. Samadi joined Lenox Hill Hospital in 2013 and brought his team with him. Although his emphasis on personalized medicine leads him to perform the operation without the assistance of physicians’ assistants or fellows, Dr. Samadi says the teams in the operating room, the recovery unit and the front office are extremely important to the department’s success.
“When I was considering the move to Lenox Hill Hospital, I reached out to my team to gauge their response, and they all signed on to make the move,” he says. “We’ve relocated a multispecialty program made up of expert physicians and providers who have years of experience collaborating with each other. In the past year, we’ve performed more than 800 surgeries with excellent outcomes. Our track record of success is recognized nationally and internationally, and we have welcomed patients from more than 45 countries and all 50 states.”
Dr. Samadi and his surgical team have been operating together for a decade.
Prostate cancer patients enjoy individualized care at Lenox Hill Hospital’s private unit for Dr. Samadi’s patients.
The operating room team is an essential component of surgical success. Consistency is the key when it comes to surgery, and keeping the team together helped Dr. Samadi and the Lenox Hill Robotic Surgery Department maintain unimpeachable standards of care.
“I work with dedicated teams who are familiar with my methods,” Dr. Samadi says. “They know what I need before I say anything, and they can read my body language. Together, we’ve performed nearly 6,000 robot-assisted laparoscopic surgeries, and their experience enhances operational efficiency and safety. We expedite recovery because we’re able to reduce operative times and minimize the amounts of anesthesia patients require.”
For additional information regarding Dr. Samadi and SMART prostatectomy, visit www.smart-surgery.com.