Robotic Assisted Laparoscopic Prostatectomy Performed after Previous Suprapubic Prostatectomy

Current Trends in Incidence and Management of T1a and T1b Prostate Cancer

Prostate cancer (PCa) identified incidentally (iPCa) after surgical treatment for symptomatic benign prostatic hyperplasia (BPH) causing lower urinary tract symptoms (LUTS) is considered low risk by the most current guidelines. Management protocols for iPCa are conservative and are identical to other prostate cancers classified as having favorable prognoses. The objectives of this paper are to discuss the incidence of iPCa stratified by BPH procedure, to highlight predictors of cancer progression, and to propose potential modifications to mainstream guidelines for the optimal management of iPCa. The correlation between the rate of iPCa detection and the method of BPH surgery is not clearly defined. Old age, small prostate volume, and high pre-operative prostate-specific antigen (PSA) are associated with an increased likelihood of detecting iPCa. PSA and tumor grade are strong predictors of cancer progression and can be used along with magnetic resonance imaging (MRI) and potential confirmatory biopsies to determine disease management. In instances that iPCa requires treatment, radical prostatectomy (RP), radiation therapy, and androgen deprivation therapy all have oncologic benefits but may be associated with increased risk after the BPH surgery. It is advised that patients with low to favorable intermediate-risk prostate cancer undergo post-operative PSA measurement and prostate MRI imaging before electing to choose between observation, surveillance without confirmatory biopsy, immediate confirmatory biopsy, or active treatment. Subdividing the binary T1a/b cancer staging into more categories with ranging percentages of malignant tissue would be a helpful first step in tailoring the management of iPCa.

Robotic assisted laparoscopic radical prostatectomy following open trans-vesical adenomectomy: A single centre experience and review of the literature

Introduction:

Robotic assisted laparoscopic radical prostatectomy (RALRP) following endoscopic resection of the prostate is known to be feasible with good outcomes. However, the literature evidence is limited on the feasibility and outcomes of RALRP following open prostatic surgery. In this study, our aim was to report our experience with RALRP in patients who had undergone trans-vesical adenomectomy of the prostate in the past.

Patients and methods:

We reviewed our prospectively maintained database of men treated with RALRP at our institution to identify patients with previous history of open suprapubic trans-vesical adenomectomy, between 2016 and 2020. Data were collected on demographic information, interventions, oncological outcomes and follow-up.

Results:

Out of 362 patients, four individuals were identified that had previous open suprapubic trans-vesical adenomectomy. The mean age was 71 years with a mean pre-operative prostate specific antigen (PSA) of 11.35 ng/ml, and an average of 10 years after their trans-vesical adenomectomy. The mean console time was 119 min with an average estimated blood loss of 137.5 ml and 75% underwent lymphadenectomy. Post-operatively, all patients were discharged after 1 day with their urinary catheters removed at 7 days post-op. For one of the patients, a urine leak was identified, and his pelvic drain was removed at 5 days instead of 1 day as for the other three patients. No other complications were noted within 30 days. The average prostate weight was 54.7 g with all specimens being T3a R0. At 6 weeks follow-up, PSA was undetectable, three patients reported full continence and 1 was using two pads/day.

Conclusion:

RALRP following previous open trans-vesical prostatectomy is feasible and safe with excellent oncological outcomes. They are, however, more challenging and cumbersome with increased console time.

Challenging Case: Robot-Assisted Laparoscopic Prostatectomy After Prior Suprapubic Open Prostatectomy

Introduction: Given the ubiquity of robot-assisted laparoscopic prostatectomy (RALP) for treatment of localized prostate cancer, more surgeons are encountering challenging cases, either secondary to difficult anatomy, prior abdominal surgery, or prior radiation therapy. Our case is of RALP in a patient after prior suprapubic prostatectomy. Case Presentation: A 61-year-old otherwise healthy Hispanic gentleman presented for consultation after being found to have Gleason 4 + 4 = 8 prostate cancer on transrectal ultrasound-guided biopsy by an outside provider in July 2017. He had previously undergone suprapubic simple prostatectomy for benign prostatic hyperplasia (BPH) in Nicaragua more than a decade prior. The patient underwent RALP with bilateral nerve sparing in September 2017. The surgery was challenging in that extensive lysis of adhesions had to be performed and typical dissecting planes at the bladder neck and apex were distorted, insofar as meticulous care was taken to judiciously use thermal energy and rely on blunt dissection at these critical junctures. That being said, there were no operative or postoperative complications, the patient was discharged on postoperative day 1, and at 3-month follow-up, the patient was fully continent, maintained erections adequate for sexual intercourse, and had a prostate specific antigen <0.1. Pathology report returned Gleason 3 + 3 = 6 disease with negative surgical margins. Discussion: There is only one other example in the literature of RALP being performed after prior suprapubic prostatectomy. Our large RALP case volume (>5000 patients for a single surgeon and counting) provided us with the necessary experience required for encountering atypical anatomy, and thereby contributed to our patient's effective surgical outcome, both oncologic and functional. Conclusion: RALP for treatment of prostate cancer is a safe and appropriate option in men who have previously undergone suprapubic open prostatectomy for BPH, especially in the hands of an experienced surgeon.