How the S.P.E.C.I.A.L. ™ Technique Ensures Nerve Preservation During Prostate Removal
Removing a prostate is very delicate work. To ensure a patient’s return of erectile function following prostate removal, the surgeon must take care to preserve the delicate bundles of nerves, arteries and veins near the prostate. The surgeon must avoid cutting, burning, and tying off these structures, leaving them as undisturbed as possible. The challenging nature of this task led Dr. Miller to develop the S.P.E.C.I.A.L. ™ technique (Sequential Pre-emptive Exposure of Cavernosal Innervation with Atraumatic Ligation).
During prostate removal, a surgeon faces two challenges. First, he must separate the nerve bundles from the surface of the prostate capsule without cutting the main nerve trunks. Second, he must also control the vessels that supply blood to the prostate without damaging the neighboring bundle of neurovascular 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.
Surgeons have developed three common techniques to deal with this problem of controlling the prostate’s blood supply. The first is coagulation with heat, otherwise known as ”thermal.” But coagulation runs the risk of damaging adjacent nerves and distorting the appearance of the surrounding anatomy. Another method involves the application of plastic or metal clips, placed by the surgical assistant, forcing the surgeon to relinquish some control. However, if a clip falls off, or if a blood vessel was cut without clipping, finding and controlling the bleeding end could be very difficult. The third method involves the 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 all three of these methods.
With the S.P.E.C.I.A.L. ™ technique, a dissolvable suture is placed around half of the blood vessels on each side of the prostate, securing nearly 80 percent of the blood supply. Smaller blood vessels will usually stop bleeding on their own, but the needle and dissolvable suture are readily 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 vessels 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. 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:
1. Full surgeon control and confidence
2. No thermal (burn) injury
3. Excellent views of the prostate capsule surface
4. Less mechanical trauma and damage to delicate nerve tissue
5. Only dissolvable material used near the nerves
6. Improved erectile function after recovery
Dr. Miller is known for his dedication to innovative surgical techniques and excellent patient care. Learn more about him and his dedicated team at his website, www.scottdmillermd.com.
