Surgical treatment of local recurrence after radical prostatectomy: Robot-assisted surgical approach combined with three-dimensional virtual reconstruction

Abstract

The treatment of local recurrence after radical prostatectomy and salvage pelvic irradiation, has no consensus in the literature. A surgical approach is possible, the main benefit of which is delaying an androgen blockade.

We present a patient who evolved with local recurrence in this scenario. He underwent a salvage robotic surgery. The surgical planning included anatomical reconstruction in a virtual three-dimensional model.

There is no standard therapeutic modality. Few studies have looked at stereotactic radiotherapy and surgery, whose main benefits have been delaying the need for androgen blockade and metastatic progression.

Salvage surgery presented encouraging short-term results and lower toxicity.

1 Introduction

The biochemical recurrence of prostate cancer after radical prostatectomy is defined by serum prostate-specific antigen (PSA) levels above 0.2 ng/ml in at least two measurements. Considering traditional imaging tests, such laboratory alteration can precede the appearance of clinically detectable lesions by up to 8 years. It is estimated that approximately 30 % of patients may evolve in this way, even considering curative treatment.

Recently, with the introduction of prostate-specific membrane antigen positron emission tomography (PET-PSMA), there has been a significant improvement in the detection of recurrence, especially considering PSA values above 0.5 ng/ml. Its benefit, in this scenario, is to increase the therapeutic success of local therapies.

The treatment of local recurrence after radical prostatectomy is classically performed through radiotherapy from the surgical bed, which results demonstrate an increase in overall survival and specific cancer Considering the context of local recurrence, even after salvage pelvic irradiation, there are few data available in literature on the best treatment. The objective of this report is to describe the robot-assisted laparoscopic surgical technique performed by our team, in addition to demonstrating the safety and efficacy of the procedure.

2 Case presentation

A 74-year-old male patient, who underwent laparoscopic radical prostatectomy in 2017. The anatomopathological study showed ISUP 2 in the right prostate apex with focally compromised surgical margins. The patient required salvage radiotherapy in the surgical bed 2 years after the procedure due to biochemical recurrence with serum PSA levels of 0.56 ng/mL. He maintained urological follow-up and, in the following year, after a new PSA elevation (3.74 ng/mL in October 2020), he underwent a PET-PSMA that identified a positive 0.9cm lymph node in the right internal iliac chain. At the time, the hormone blockade was initiated for a total duration of 15 months and 36 radiotherapy sessions in the lymphatic chain and surgical bed were done. After another 2 years, in 2024 the serum PSA dosage increased again (1.32ng/mL in April and 1.78ng/ml in July). Serum testosterone levels were normal, since hormonal blockade had already been discontinued 2 years ago . At this time, after another PET-PSMA scan, a nodular lesion was identified in a topography corresponding to the left seminal vesicle, measuring 1 cm in diameter, compatible with locoregional recurrence ( Fig. 1 a and b ).

The treatment performed was salvage surgery, which consisted of extended pelvic lymphadenectomy, involving the obturator, internal and external iliac chains bilaterally, in addition to the removal of the suspicious area detected by preoperative imaging tests ( Fig. 2 a and b ). The surgical planning included anatomical reconstruction in a virtual three-dimensional model, which facilitated intraoperative navigation ( Fig. 3 ).