Discover the hidden complexity behind nerve-sparing prostate surgery. In this masterclass, Ash Tewari MBBS, MCh, FRCS (Hon.) introduces the concept of the neural hammock—a groundbreaking anatomical model that redefines how surgeons approach robotic prostatectomy. Explore the intricate relationship between nerves and prostate cancer, and learn how surgical precision can preserve function and improve patient outcomes.
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I'm going to make a presentation about nerves and robotic radical prostatectomy here from New York and hope I will see you all in New York in the challenges in December 3rd to 6th of this year. Topic of my. Presentation today is all about nerve sparing robotic radical prostatectomy. There are not many operations. In which there is in complexity to a point that not only that we have to take all the cancer out, but we have to ensure preserving the nerves which are not easy to preserve and reconnecting back everything so that the continence also works very well. This is an operation in one word, an operation of contrast, operation of challenges, operation of competing goal management. I want you to go through a journey which I have gone through in which I took what was available to understand about this process. Started deeper diving into the neuroanatomy of the pelvis. Getting adapted to the robotic platform, going through a journey of transitioning from an open to robotic radical prostatectomy. And then refining the very operation which now we call robotic nerve sparing radical prostatectomy, and there have been many people who have contributed to this journey and hopefully at the end of it, I'll be able to share that. So robotic radical prostatectomy is in one of the most common operations. The history goes in 1987, Doctor Walsh, when he was visiting Europe, happened to integrate or happened to interact with an anatomist. Doctor Peter Donker from Leiden University led him to start visualizing that not every radical prostatectomy needs to result in an A sexual dysfunction which was very common at that time. No one actually understood that there are nerves around the prostate which can be preserved, and he started the entire journey of nerve sparing radical prostatectomy. And what we are doing today is still on those same principles, just the robotic platform has given us a different angle, different magnification, and possibly a bloodless field. So we are trying to refine on that, and I was lucky to be trained by his trainee, that is Doctor Mennon, who started in a year 2000 robotic program. I was there, as you can see in this picture, I was on one of the critical persons at that time going through the training, but I was a little bit experienced surgeon at that time, so I can understand what was important and he. With Bertrand Gero, Guy Valencian, and the rest of the team in Vattioti Urology Institute, started embarking upon the robotic surgery. What I got interested very early on was the anatomy and the nerve sparing part of this operation, and I took this journey a little bit more visually, as you can see on the figures on the right side. I tried to visualize the neuroanatomy just the way it was applying for the robotic platform. I went through revisiting the anatomy lab, revisiting the tissue, recombining everything on the robotic platform, and let's see what I learned. I got very experienced in using the earlier versions of the robot. I was very good in port placement and also assisting in that process. This is a picture from very early on, I think it must be a 2000 and 2002 when we were doing our 1st 1000 robotic prostatectomies when I was still in Michigan. I want to highlight why prostate cancer surgery is important enough for us to refocus. It's very common. A lot of people do do a good job, but I'm just highlighting why it is challenging and why is it challenging even now. There are not many operations in which a surgeon gets judged by just not by what he or she took it out, but by the incontinence which can happen in in very awkward moments and lack of sexual function, which is an important tool. You need to understand that the prostate cancer is a very common cancer and it's about to increase in its incidence over the next 20 years, that's been the prediction from the Lancet Commission. We are very good in curing prostate cancer because 95% of these patients are going to live a long life. Only challenges many of these patients don't regain quality of life, and that is the reason we have to focus on what can be done to not just give them a cure, but possibly give them a reason to live for so that their quality of life is also good. I don't have to highlight that the incidence of erectile dysfunction varies a lot. It varies based on what kind of cancer we are dealing with, what ages of the patient, what's the stage of the cancer, and sometimes, based on the experience, what we have in performing this operation, this is a little delicate operation. And outcomes can vary based on multiple factors, and let's see what we can do to minimize this changes, minimize this alterations which can happen to the patient's life. This figure highlights that this is an operation not going to be easy. You can visualize here that the prostate is sandwiched between the bladder and the urethra behind the pubic bone in front of the rectum. Encased within a very vascular tissue, lots of veins, and then the pubic bone is kind of giving a very little access to that space. And we as a surgeon are supposed to take just the prostate out and leave everything else intact and then functional. That's where the challenge happens and that's the reason I want you to understand this is a delicate operation. I want you to see these flowers, these flowers. They are representative of two things the delicacy or the vulnerability of these flowers. They are very fragile. They are very delicate. So are the nerves which we are trying to save around the prostate. Second part is the thickness of the nerve in this flower is almost the same, less than 1 millimeter thickness of that neurovascular bundle and these flower petals make them very delicate, and these flowers are shining in front of us. Nerves, they don't shine. They are hiding around the prostate, so I want to highlight certain things which I have learned about this operation. You have to think about the damage to the nerve, doesn't need to be an avulsion, doesn't need to be a crush, doesn't need to be an. This engagement doesn't need to be totally destroyed. They can be subtle A vascular phenomena can happen. Inflammatory phenomena can happen. Crush can happen, traction can happen. a little bit of an extra pull can happen, and all of that may not have an impact on another connective tissue, but the nerve tissue, which only relies on the neural conductivity, is very delicate. It is relying on the calcium and sodium. Channels which are allowing the nerves to go from one place to the other, and if there is a little disruption, I think it impacts the return of the function and the function here is the sexuality. So we have to rethink in our mind what we are trying to save and preserve and what damage can happen. Many times we get to know that whether the cancer was taken out in totality or not, if not at the same time, within 7 days we get to know. But the function comes in months. So if we don't see the function, sometimes it's difficult to preserve the function, and that's a different mindset as a surgeon we have to have, and then I personally think that this is like a brain surgery in the pelvis. It's a very complex organ, autonomic nerves are very delicate, prostate cancer is very common, and then prostate cancer tends to have two other phenomena which I will touch upon it in the next few slides. This is what. Doctor Walsh started with in understanding the neuro anatomy, and he was so excited about it. He understood the anatomy. He went into the cadavers. He went and drew the arts, drew the drawings to understand how these nerves were arranged around the prostate, and he came up with the concept of left and a right neurovascular bundle. And over years his own understanding about the neurovascular bundle vault, and he started talking about the anterior high anterior release and everything. But this was the original figure, and it inspires us all who is embarking upon the journey that this kind of an understanding, this kind of in depth is what led for us to establish a field of nerve sparing prosthetic. I would talk about nerve sparing robotic prosthetic B. This is a figure of the pelvic nerves, not by my research group, by other anatomists or the urologists, or the people who are interested in this field. And as you can see, most of the work was done in what we call cadavers, which were embalmed cadavers or the formerly in fixed cadavers, and structures you can see there are multiple nerves around the prostate, but they were not that clear to take this image, take it to the operating room. And operate upon and then save the nerves was a little bit unchallenging task for me. As you can see, if I'm looking for a neurovascular bundle on the left and a neurovascular bundle on the right, I'm seeing a meshwork of nerve. These nerves are intermingled with the blood vessels. These nerves are not lying exposed just like what we are seeing here. They are concealed within the fascial layer around the prostate, underneath the vein, sometimes superficial to the vein sometimes. So it's a complex anatomy. So the first step for me was to make this a little bit simple. So I started imaging the prosthetic and periprosthetic tissue in a different ways, and what you are seeing here is a multiphoton microscopy, which is in real time imaging. What you can see the nerve, you can see the cancer cells, you can see how these things are all jumbled up intermingled together in a periprosthetic tissue. So there is a prostate There is a prosthetic capsule. Outside the prosthetic capsule. There are ganglions. There are nerves. There are fibers. There is a meshwork. There are some fatty tissue. There are some layers of the membrane and ultimately there is a membranous and muscular layers, leator eye is there that all is within a few millimeters and interspersed between them are the nerves that we are trying to save. There is one more challenge which I will talk about it that. Is the biology of this cancer is a biology of extracapsular extension. I don't want to dwell upon it, the whole figure here, but I started visualizing the whole prostate cancer journey and what you are seeing is in prosthetic capsule which I have drawn, and inside the prosthetic capsule there is an asinous structure, and this ainous structure actually has normal glands. There are early glandular architectures or a Gleason 6, and then there are cancers which are more aggressive and what I'm drawing here. Are the periprosthetic neural complex which is going on the side of the prostate but still ascending some of the branches within the prostate because the nerves, they coordinate the entire bodily functions, not just the cavernal nerve which is going to the carpora sponiosa and cavernosa, but there are nerves which are going to the bladder, to the bladder neck, to the seminal vesicle, to the prostate, to the urethra. All that is happening here and what you are seeing that sometimes that the cancer is happening inside the prostate. This cancer can be an early grade, or sometimes it can be a more aggressive one just the way I'm drawing here, and this aggressive cancer, at least in the case of a prostate, has a special tendency, what we call perineural invasion. I possibly will have another slide show about the perineural invasion, but the simplified version is cancer cells wrap around the prostate. They go outside and then they are intermingling with an extra prosthetic nerves, the same nerves which we are trying to save may be seedling for a cancer and maybe will become a source of a recurrence. So that's was my first understanding. It was very early on that I started defining the periprosthetic anatomy in different zones, different grades, that you can tailor this entire operation based on what you have to deal with. And that led us to predict who is likely to have an extracapsular extension. That's not the topic of this talk, but you can refine the operation in a way that you can tackle every bit of it, if it's in inside the prostate, you have a grade one nerve swearing. If it is very wide, then you have to excise that discussion will come a little later in the slide presentation. I don't want to dwell too much upon this, but I want you to know that in prostate cancer there is a secret love affair going on between the nerves and the prostate cancer cells, not just that it allows for the perineural invasion, as you can see in the slides here, in which we have SA 100 and then a PSMA stain showing how the cancer cells are wrapping around the nerve fibers, but there is an exchange of goodies. Prosthetic cells produce certain chemicals. These serve as a nerve growth, nerve attraction factors. Nerve cells, they produce some nerve growth factors and they interact with the prostate cancer cells. So there is a neural genesis and the cancer cells clonal evolution happening between the two different kinds of cells. Cancer cells become more aggressive right under the watch of the nerves and especially in in prostate cancer, and then ultimately allows to further a perineural invasion. That's the nerve we are trying to save, because we have to make a decision whether it's a friendly nerve which is going to give us an erection in the patient, or is it an unfriendly nerve which has already changed sides and is colluding with the cancer cells. It's very fine to allocate balance, so as a surgeon, I'm not just a surgeon, I have to be a detective also, and detective has to have all the tools, so we use the MRIs, the exact scan, the PSMA, but this is a journey and I'm not going to sweat on that discussion right now, but you need to understand, extracapsular extension, perineural invasion, relationship between nerves and prostate cancer, it makes the job much more challenging. How do we resolve that? First thing we can do is to have a better understanding of the anatomy. We saw those complex cadaver dissections in which there was a meshwork of tissue around the prostate in the pelvis, and we were supposed to use that as a template to guide us to do the surgery. I wanted to make it more easy. Then I didn't, I, I want to touch upon the individualization a little bit, but ultimately it'll boil around the technique. Understand anatomy better, choose the right patient, and then work on your craft, and that's what I will try to show. So in the anatomy, I wanted to simplify it from a surgical standpoint and the first thing I saw that. It was a little bit too simplistic for me to visualize the nerves as a neurovascular bundle on the left and neurovascular bundle on the right, because I was finding there were a lot of cross connectivity between the nerves on either side. They were interfacing behind the prostate. They were interconnecting in the side of the prostate, and they were actually going more anterior at the apex many times to me. In a simplified way, Simon looked more like a hammock, a hammock of nerve from the left and the right side intermingled with a lot of ganglions, and on that hammock was the prostate sitting. Depending upon how rapidly the prostate grew, how large the prostate grew, the hammer got de-shaped, deformed, or adapted to the pelvic space. You add in some inflammation. You add in some vessels. It becomes even more complicated. But let's first visualize that nerves around the prostate are like a hammock. I started this journey by going back into the fresh cadaver, the very thing which I didn't like in the embalmed cadavers in which there was a formally fixed cadavers. I wanted to see the structure just the way I see during the surgery. So this was in early 2000 to 2003. I worked upon going through the neuroanatomy, re-understanding what the structures look like. And then showing you that the nerves are a little bit more complex, and I came up with the concept that the nerves could be a predominant neurovascular bundle, could be a neurovascular plate and their accessory nerves, and these are the pictures which showed me that how to approach this cancer and how to approach this operation a little bit from a robotic standpoint. We started with the slides which we saw before. And on the left side, I want you to show a slide which has been shared to me from Doctor Takinaka, a great friend and a collaborator from Japan. He spent a year with me when I was early on in New York, and he sent me the slide, and it shows that the bifurcation of aorta is there. There is a hypogastric plexus and the hypogastric nerve on the left and the right going down towards the bladder. On the deeper part on the left side, there is a sacral 2, sacral 3, sacral 4 parasopathetic autonomic nerves are coming out. They are all intermingling around the prostate. The prostate is there, bladder is there, but you cannot see the nerves. You see the tissue in that area, and this is a French cadaver, so you have a luxury of seeing things a little bit more clean. You're not seeing much of the blood. On the right side is a different cadaver dissected by me. And I wanted to get into the depth of this proximal neurovascular plate, the neurovascular bundle, the accessory nerves, and you can see. That how the nerves are arranged around the prostate, you're seeing and pouting seminal vesicle, the prostate, and a meshwork of a nerve, I'm not seeing a very predefined bundle what I'm seeing in the meshwork of a nerve. That meshwork of nerve hides in the tissue just like what you're seeing on the left side, but as a surgeon, we are supposed to save these nerves without even seeing them. So I want you to focus on this and see what you see over time. I've tried to superimpose this and show you that these same nerves are hiding in the tissue around the prostate, around the bladder, around the seminal vesicle, and it's important for us to not only understand the neural anatomy. The curves of the nerves, the pelvic plexus, the accessory nerves, but we need to understand where the ganglions are. We need to understand how they intermingle with the vessels. We need to understand how this all is concealed in the very delicate fashion layers around the prostate, because as a surgeon we have to get close to the prostate, take the prostate out and leave these structures behind. So this is the first anatomical picture I want you to visualize in your mind that this is how the nerves are. When there is no blood, when we have access to the lateral side of the prostate, which we don't have a luxury when we are doing it in a live patient, this is how it looks like. Once we have that visual in our mind, we can potentially embark upon a robotic prostatectomy and visualize and anticipate where these nerves will be. As you can understand, if it was just a nerve on the left and a nerve on the right, things would have been much more easier because the collecting branches between the neurovascular bundles on the other side, the other is the delicate structures, and I think every component of this neural hammock ultimately contributes to the functional return. On one side is an erectile function that is having an erection, other side is an orgasmic function. All that combined and tied to the continence recovery, this entire meshwork, every nerve fiber has some role to play. So we as a surgeon have to figure out to least disrupt this neurovascular hammock and branches of hammock are hiding within the layers of the fascia. So I'm trying to describe it a little bit here. You can see the figure on the left. It's a simplified version of the hammock. On the right side, I'll get on to the more detail as to how this hammock is in a 3D model, but in the center is part of an atlas which I'm trying to put together a urovascular hammock right in front of the rectum. In front or within the layers of the denonvilar fascia, how the prostate and the bladder are sitting on it, how they are interacting with the seminal vesicles, how the urethra is interacting with it at the apex, and on the right side I have drawn a figure which kind of highlights that this hammock is not only present all around the prostate. It is within the layers, and these layers have got a penetrating vascular branches which are going into the prostate, and we as a surgeon have to disconnect these branches with the least bit of an energy or least bit of a disruption to these nerve branches and then slowly tease the prostate out and that's where the art of the prostatectomy will come. Let's look through the grade concept, and I have already shown this picture before, but I want you to visualize on the left side the picture in which there is a periprosthetic tissue, that periprosthetic tissue has a prosthetic capsule, some of the nerve fibers which are in green. There is a venous and an arterial component, then bulk of the nerves on the right side, and then some loose areolar tissue, some lymphatics, some ganglion, some muscle fibers, and then fascia, which we call the levator fascia, the lateralmost part is what we call the leva and eye muscle. Simplified version Capsule prosthetic fascia. Some nerves, veins and arteries, more nerves, los tissue, levato fascia, liberated and Imersal everything around is either known as the lateral prosthetic fascia or the periprosthetic fascia, and you can see that actually sometimes in an in an MRI that the capsule and the layers are around the prostate, but. We need to go into a little bit more details, and you can appreciate here on the picture prostate is on the right side of the screen, and you're barely seeing the prosthetic capsule. Beyond the capsule you can see some greenish structures which are the finer nerves. They may be the branches of the same nerve which are penetrating actually within the prostate, and some of them may be traveling towards the exiting the capsule or exiting the pelvis, but most of the bigger branches and the ganglions are more lateral. And you can see the veins, veins are collapsed here, some arteries are in the red, they are more muscular, and then there is a partial layer and then ultimately you can see the muscle layers. So this is the deeper anatomy of the periprosthetic layers, which is within a few millimeters, and that's the reason, as I say, this is an operation about the millimeters. My team has been very thoughtful in putting together a whole 3D model to integrate from an applied standpoint this complex anatomy into something which is very understandable, very understandable for someone who is embarking upon the surgery, who understands what the layers around the prostate are, what is the tissue which is in the front, what we call. Anterior fibromuscular stroma and how the whole structures are, I will be talking a little bit about it, then it talks about the different kinds of nerves. It talks about autonomic sympathetic nerves. It talks about autonomic parasympathetic nerves. It talks about some of the somatic fibers, it talks about the vasective and other kinds of nerve fibers which are there. It talks about the different sphincter muscles which are there. It talks about the people perinealis, it talks about the rectal urethralis, it talks about the sphincter. It talks about the omega shape of the sphincter, and it talks about the bladder neck. All that complex anatomy is simplified here and you can appreciate that into this 3D model. I must give credit to one of my previous fellows, Sneha, who helped me in putting this all together, went through the multiple iterations, and then my current resident Asher Mendel helped in putting it all together. And I think he's trying to get this thing published with the surgery in the European neurology, we will find out very soon, but this is the 3D model which can help in us understanding a better hammock how the neurovascular tissue is there, and you can see it here, taking the prostate out from this complex meshwork, I think it takes a mission impossible mindset. Anyway, let's go to the next layer. Next part of the discussion after understanding the anatomy. Is to understand how surgical technique is done, and I want you to see two different ways of doing the same thing. Obviously The left side surgeon is very delicate. Left side surgeon is very appropriate in the traction that it's being used. Left side surgeon is peeling the planes away very easily and very delicately. And the other side is where you get damage to the structures, you can get positive margin, while it can be done in the same delicately with the same instruments, same operation that cannot be quantified. But that can be appreciated and that's what the technique part I'm talking about, so. The Art of nerve sparing is very relevant in this operation. There are not many operations in which you talk about an art, but in robotic radical prostatectomy, there is an element of craft which under which depends on an anatomical understanding. Which depends on modifying it according to the actual particular patient's data, it also thinks about not the structural preservation, but the functional preservation, and ultimately I'll talk a little bit about a new technique which we have developed what we call saline dissection or an hydrodissection that will ultimately show you what we saw in the anatomy in the real patient, and we are about to come to that. Talking about the technique, I cannot. Explain it just by talking about it. I want you to see that doing this operation can be done in many different ways. There are access issues. You can get to the prostate from behind in the pouch of Douglas we call red sparing. You can get it by getting into the extraperitoneal space. You can get it by getting inside the bladder. You can get it by staying close to the bladder and not touching too much anteriorly, and that's exactly what I have been doing here and I want you to see a little bit of how this thing can be done, and I'm trying to find the plane. Between the anterior fibromuscular stroma, the hooded structures, and prostitive vesicular ligaments, and finding the right junction between the prostate and the urethra, this is what you're seeing here, and with experience, you can find a plane which is just right, and you can see that I'm trying to find the right plane for the prostate vesicle junction here. Is where the urethra, prosthetic urethra is joining the bladder and slowly I can tease it off and you can appreciate. A very appropriate size bladder neck junction. So this is what we call a bladder neck preservation along with the hood structure preservation, and you will be seeing a catheter becoming visible very soon. So even this is an art of prostatectomy to find the right junction between the prostate and the bladder neck, and here you can see it's in very small bladder neck. I don't do that in every patient. If they have more cancer at the base, if they're having more cancer in the midline, if they have a median lobe, if they have a large prostate, it's not possible if they have a high grade cancer, it's not, but in the right patient, it is possible to do it, and this becomes a very easy and osmosis down the road. I want you to see something else. Here I am focusing not just on the nerves but also on the sphinctic structures, the membranous urethra, the in sphincter, the people perinealis muscle, the transversus perinea, the rectal urethralis. And how this all is jam packed within the denomters layer. This is my understanding. I will not dwell upon it too much because that understanding led me to develop what we call a ho technique in which we started saving the anterior structures so that the patients have an earlier continence, and I'm going to show you that in this picture. At this point, what you're seeing that vast and seminal vesicles have been dissected up. They have been lifted up with using the foret arm on the left side, and I'm trying to delicately find a plane between the rectum, the the nonvears fascia, and the posterior capsule of the prostate, and you can develop this plane delicately if you spend enough time and especially if there is no thrombophlebitis, no prostatitis, no hematoma or no inflammation there. So it gives some patients, you can see that I'm sticking in the midline. On the hammock you can see that the hammock branches are coming from the side, and here I am staying in the midline and in the midline if I get just close to the capsule of the prostate, I can slowly march on the left and the right side, and that's what we call entry into the tewari triangle or the entry into the neurovascular triangle between the denovious layer. Between the prosthetic capsule and between the prosthetic fascia and the lateral prosthetic fascia, there is a junction point which meets there, and at that junction point there are some penetrating blood vessels which are coming into the prostate at the base of the seminal vesicle. A neurovascular bundle is actually hiding in that triangle. To get into that triangle is what we are trying to work and as you can see, it takes a little bit up in patients, a little bit up in sharp dissection. Identification of some of the blood vessels and sometimes cutting the small blood vessels just like that, and I have come up with a term which we call micro zapping, you can use a little bit of a cautery here, it's not a real cautery use, but you can take care of the capillary of the blood vessel right at the point where it is entering into the capsule and spend some time, you do that on the left. You do that on the right, you take help from your assistant, you develop a plane, and then slowly you get onto, and then you can march laterally on this thing, and this is, you continue on it. The plane develops and as long as you are appreciative of the capsule and the veins and then how the periprosthetic fascia is arranged, you can develop this plane and then you can march more anterior laterally and then ultimately you'll come to the point on the more anterior part. Here is what you are seeing the development of the hood, and this is an inflamed vein which we are seeing and a blood vessel was entering. We cut it out and then slowly the plane opens up and all the nerves. All the periprosthetic plexes, all the hammock branches are in the tissue which has been left, and what you are seeing that slowly we are marching towards the apex, and then finally we will have an anterior structure which is very contributing to the continence is preserved. This is what we call the hood technique, and this is the same thing is being done on the contralateral site, and you can appreciate that there is a little bit of a bulb bulge there which could be BPH, could be the cancer. The next thing comes is that we can show you the nerves better than what we had seen even in the cadavers, and we have developed what we call a hydrodissection technique, and that technique started developing by me injecting something in the periprosthetic space between the layers of the denonvius fascia and the prosthetic capsule. You can see that there is a plane developing, and that plane can separate everything away. So on the top is the prosthetic capsule and the prostate itself, and in the bottom are the periprosthetic tissue, the same hammock which we are talking about it, and we separated the hammock from in 1 millimeter distance to 2 millimeter 5 millimeter distance just by injecting something in that plane. It's happening in real time and as you can see when we are injecting it, this is how it looks like if you're doing it in intraoperatively and you can see that the structures are floating away. You can actually see that the nerves will float away in front of you and you saw that the yellow structures nerve will be floating away. This is one of the most delicate way of floating or moving the nerves away from the surgical field, and I want you to appreciate what it means to have a hydroddi and it doesn't need to be injected through the transrectal route. I can do that intraoperatively also. There are two benefits happening one, that I can dissect structures away from the prosthetic capsule and in one of the most delicate ways. And the second. The fascia, the tissue, the structures around the prostate, they change their visuals, they become transparent. So I start seeing things in much more detail before even coming onto the damaging the nerve. So these are the nerves which we were trying to save, and you can see there are two different layers I have gone into. The first layer was already there, and I'm going into the second layer, and you can appreciate that how the nerves are hiding in that area. This is what I call the left side of the neural hammock where the ganglion and everything is there, and the reason I'm doing it because I was worried about that there may be a little bit more cancer on one of the sides. I can do it in real time if there is a patient in whom there is a little bit of a fibrosis, a little bit of an extracapsular risk, and the tissue is not opening very easily, I can possibly do it in the real time, and I will show this in a way that you will appreciate that hydro dissection in the real time can separate the tissue right in front of you. And you can appreciate that the plane opens up and the tissue can separate and peel away. It's a very clean peel, and I didn't do anything else other than injecting some saline with a needle in that area, so this isn't hydrodissection, but. I promise you that I will show you the nerve from an anatomic dissection to real radical prostatectomy, and this is what you get to see. I will show you on the left side of the prostate, I'm starting dissection right there, you can open up the planes a little bit here. You can open up the planes a little bit here. You develop 2nd and 3rd layer of hydrodissection, and once you have done it, you can. Use the scissors to dissect it out and now these are the magic nerves, these are the mystery nerves, these are the nerves which we have been trying to find, they are hiding right in that tissue and because of the hydrodissection, I can see them very clearly and if you can see them, you can possibly dissect them out much more delicately, but. I have one last thing to share with you because I have been developing an AI based model in collaboration with the team, and that will tell you that even before we see the nerves, I can train an AI base. This is the same video. This is the same video in which I was showing the nerves, but here I can possibly show you a little bit more. Real time, that model has been trained to recognize the nerve, and it will glow. Nothing has been injected. It is not needing a change of the fluorescence or change of the firefly. These nerves are becoming visible because the model has been trained to identify the nerves. This is the preliminary work, but as you can see, it's easy to identify the nerve, and that what in my mind. Is the next step for us to create a lane, create a training model in which even a new person who is embarking upon this journey doesn't have to have gone through 10 last 1020 years of surgeries, can have a better control, better understanding of the neuroanatomy. So what I showed you that it's been a long journey about transitioning from an open to radical robotic radical prostatectomy and especially nerves. I try to spend time understanding about the neuroanatomy. I tried to decipher what technical tools can be used. Now we are developing an AI based model to demonstrate the whole neurovascular bundle, and I'm finally ready to share that in a sizable number of patients, 9 in 10 patients give some time, give. 1 year, 1.5 year, they will get their function back, at least in some form or other, and we are always working on refining it a little bit better. Even early on, up to 40% of the patients can get the function back and within less than 3 months. So this is a pretty promising journey for us, and I'm really thankful to everyone who has been inspiring to me. I want to make sure that you all come and be with us in New York between 3rd to 6th of December, we will have the similar setting here. Thank you very much.
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