The S.P.E.C.I.A.L. Technique
Better Care for Patients – An Innovation Created by Scott D Miller, MD: The S.P.E.C.I.A.L. ™ Technique for Nerve Preservation During Robotic Prostatectomy
Return of erectile function following prostate removal requires preservation of the delicate bundles of nerves, arteries and veins near the prostate. The surgeon removing the prostate must avoid cutting, burning, and tying off these structures, leaving them as undisturbed as possible. This was the idea that led Dr. Scott Miller to develop the S.P.E.C.I.A.L. ™ technique (Sequential Pre-emptive Exposure of Cavernosal Innervation with Atraumatic Ligation).
A surgeon faces two challenges. First, as the bundles travel along the undersurface of both sides of the prostate, they send small branches into the prostate. These branches must be cut flush with the surface of the prostate capsule (the structure covering the prostate) without cutting the main nerve trunks or entering the prostate capsule. Second, the vessels that supply blood to the prostate enter the gland next to where the neurovascular bundles enter the scene. The blood supply must be controlled without damaging the neighboring nerves. Without that control there could be excessive bleeding, thereby obscuring the surgeon’s view during the most delicate and unforgiving part of the surgery. Because the blood vessels and adjoining nerve tissue can often overlap to some degree, precisely locating the delineation between the two can be very difficult, if not impossible, and too much bleeding could magnify the challenge. The S.P.E.C.I.A.L. ™ technique, on the other hand, does not require this determination.
The most common methods of controlling the prostate’s blood supply include: Coagulation with heat (”thermal”) – Coagulation runs the risk of damaging adjacent nerves and distorting the appearance of the surrounding anatomy.
Application of clips (plastic or metal) — Clips are usually placed by the surgical assistant, forcing the surgeon to relinquish some control. If a clip falls off, or if a blood vessel was cut without clipping, finding and controlling the bleeding end could be very difficult with this method.
Placement of temporary miniature vascular clamps — Temporary clamping avoids many of the problems in the other two methods, but requires difficult clamp placement with subsequent tedious oversewing of structures that may or may not bleed. The S.P.E.C.I.A.L. ™ technique avoids the problems of these three methods.
With the S.P.E.C.I.A.L. ™ technique, a dissolvable suture is placed around the first half of the vascular pedicle (blood vessels) on each side of the prostate. Since the vessel diameter becomes smaller near the nerves, nearly 80 percent of the blood supply is actually secured by this suture. Smaller blood vessels will usually stop bleeding on their own, but the needle and dissolvable suture are available to control individual blood vessels if needed. By avoiding suturing structures that would not bleed and also vessels that bleed but subsequently stop on their own, injury to nearby nerve tissue is minimized. In addition, the suture attached to the vascular pedicle can be used to hold the nerve bundle in place without actually touching the nerves. The prostate can then be delicately “lifted” from the nerves rather than having the nerves traumatically “dissected” from the prostate. As a result, the natural anatomy of the nerves, veins and arteries, along with the tissues surrounding them, is carefully maintained and normal functions are preserved.
Dr. Scott Miller’s S.P.E.C.I.A.L. ™ technique has been taught to many other surgeons and is used for most of his patients because of its many advantages:
- Full surgeon control and confidence
- No thermal (burn) injury
- Excellent views of the prostate capsule surface
- Less mechanical trauma and damage to delicate nerve tissue
- Only dissolvable material used near the nerves
- Improved erectile function after recovery