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urgical Challenges in Radical Prostatectomy

uccessful Salvage Robotic-Assistedadical Prostatectomy After External Beamadiotherapy Failure

arim Jamal, Ben Challacombe, Oussama Elhage, Rick Popert, Roger Kirby, androkar Dasgupta

e describe the first case of salvage robotic-assisted radical prostatectomy for local recurrence after external beamadiotherapy. A 50-year-old man initially underwent combined external beam radiotherapy and hormonal treatmentor Stage T2a prostate adenocarcinoma. The prostate-specific antigen level was 10.5 ng/mL, and the Gleason score was�3. Two years later, he developed biopsy-proven recurrent disease. He underwent salvage robotic-assisted radicalrostatectomy. The patient was discharged on day 1 postoperatively. The histologic analysis revealed an organ-confinedumor. His prostate-specific antigen at 3 months was �0.03 ng/mL, and he was continent. Salvage robotic-assistedadical prostatectomy is a safe and technically feasible salvage treatment for prostate cancer for which primary

adiotherapy has failed. UROLOGY 72: 1356–1358, 2008. © 2008 Elsevier Inc.

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ith a 40%-60% reported progression rate afterexternal beam radiotherapy (EBRT) for local-ized prostate cancer, 30 000 men in the

nited States alone will develop recurrence.1 This ini-ially manifests as biochemical failure, denoted by anncreasing prostate-specific antigen (PSA) level in antherwise healthy man. Biochemical recurrence andhanging findings on the digital rectal examination botharrant additional transrectal ultrasound (TRUS)-guidedrostate biopsy.

ASE REPORT50-year-old man initially presented with microscopic

ematuria in 2004. His PSA level was elevated at 10.5g/mL with a benign-feeling prostate. He underwentRUS-guided biopsy that demonstrated a Gleason score�3 tumor. He underwent 70 Gy of conformal EBRTnd 3 months of cyproterone acetate (100 mg/d) andoserelin (3.6 mg/mon) hormonal therapy. Two yearsater, he presented with hemospermia, and the digitalectal examination revealed a firm prostate consistentith previous EBRT. His PSA level was 0.7 ng/mL. TheSA trend after EBRT is shown in Figure 1. The urinaryrostate cancer antigen 3 level using the PCA3 Plus testas 1136 copies mRNA/mL (normal �35). He under-ent repeat TRUS-guided biopsy, which showed residual

rom the Department of Urology, Guy’s Hospital and King’s College London School ofedicine, London, United Kingdom; and Prostate Cancer Centre, London, UnitedingdomReprint requests: Prokar Dasgupta, MSc, MD, DLS, FRCS, FEBU, Department ofrology, Guy’s Hospital, 1st Floor, Thomas Guy House, London SE19RT UK.

t-mail: prokarurol@gmail.comSubmitted: December 8, 2007, accepted (with revisions): April 8, 2008

356 © 2008 Elsevier Inc.All Rights Reserved

umor in the right apex and right mid-zone, unclassifiabley Gleason score because of the radiotherapy effect. Mag-etic resonance imaging demonstrated a 30 cm3 glandithout evidence of capsular invasion or pelvic lymph-denopathy.

ANAGEMENTalvage robotic-assisted radical prostatectomy was per-

ormed using the da Vinci robotic system. The planesateral and posterior to the prostate were difficult todentify, in keeping with previous EBRT. However, weelieve that the excellent three-dimensional vision andagnification afforded by the da Vinci system compensated

or the lack of normal tactile feedback used in open radicalrostatectomy (RP). Particular care was taken during theosterior dissection to avoid rectal injury. An anastomosisith running 3-0 Monocryl suture was performed, with twodditional bolstering Monocryl sutures placed laterally toeduce the risk of urine leakage. The left neurovascularundle was successfully spared, because, although theatient had moderate erectile dysfunction preoperatively,e was young, and it was hoped that sparing this bundleould permit some postoperative erectile function with

he use of phosphodiesterase inhibitors. Lymph nodeissection was not done, because he was deemed to havelow risk of lymph node metastasis. With an initialleason score of 3�3, an initial PSA level of 10.5g/mL, and nonpalpable disease, his risk of lymph nodeetastasis according to the Partin nomograms was �3%

efore EBRT. Two years later, with a small increase inaseline PSA, this risk was still deemed to be low. In both

he salvage and primary setting, lymph node dissection is

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erformed according to regional cancer network guide-ines.

The total operative time was 150 minutes, with anstimated blood loss of 100 mL. The patient was dis-harged on day 1 postoperatively after drain removal.ystography (Fig. 2) performed 2 weeks later showed no

vidence of an anastamotic leak, and the catheter wasemoved.

On histologic examination, the postoperative speci-en demonstrated an organ-confined adenocarcinoma,leason score 3�3. His PSA level at 3 months was0.03 ng/mL, and he was continent, only requiring a

aily pad for security when doing strenuous activity.

OMMENThis patient underwent prostate biopsy after an elevatedrostate cancer antigen 3 level despite an unremarkableSA trend. The current use of PSA levels to predictecurrence after EBRT uses either the American Societyor Therapeutic Radiology Oncology or Houston crite-ia.2,3 Most patients are diagnosed with recurrent prostateancer �5 years after EBRT.4 At that point, many willave systemic disease, some of whom might have hadrgan-confined cancer at an earlier point. Therefore,arly detection must be the goal, if local salvage therapys to be possible. The use of novel biochemical markersuch as prostate cancer antigen 3 might enable the earlyetection of recurrence.5

Once recurrence is suspected, the patient must un-ergo TRUS-guided biopsy, the histologic interpretationf which is often problematic.6 Radiation atypia in be-ign prostate glands can be difficult to differentiate fromarcinoma.

electing Surgical Candidatesatients with local prostate cancer recurrence after EBRTan be considered for a range of salvage treatment op-ions, including radical prostatectomy, cryotherapy, an-rogen deprivation, active surveillance, and, in someenters, high-intensity focused ultrasonography.7 Of allhese options, only salvage surgery has demonstratedong-term disease-free survival.8 Any patient consideredor salvage radical prostatectomy (SRP), whether open,

PSA trend following EBRT/hormones which finished 03/2005

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igure 1. Prostate-specific antigen trend after externaleam radiotherapy/hormonal therapy, which ended March005.

aparoscopic, or robotic assisted, should be motivated, t

ROLOGY 72 (6), 2008

ave minimal comorbidities, and a good life expectancy.he tumor should be organ confined both before EBRTnd before salvage treatment. This was determined fromhe 5-year progression-free probability of 77%, 28%, and2% for organ-confined cancer, cancer with seminal ves-cle involvement, and cancer with positive lymph nodes,espectively.8 In that study, the largest series published toate, the investigators found that patients with a lowreoperative PSA level were most likely to gain long-erm disease-free survival.8 The 5-year progression-freerobability after SRP was 86%, 55%, and 28% for pa-ients with a preoperative PSA level of �4, 4-10, and10 ng/mL, respectively.9

omplications of SurgeryRP has traditionally been associated with increased mor-idity compared with standard RP. Stephenson et al.10

ound that although their complication rate was initiallyignificantly greater, patients who underwent surgery sub-equently had morbidity approaching that with de novoP. The latter cohort of patients had a decrease in the

ectal injury rate from 15% to 2%. This observationould have resulted from improved surgical experiencend technique, better patient selection, and a reductionn extraprostatic fibrosis from advances made with EBRT.he operative time, length of stay, and major complica-

ions were similar to those after standard open RP in theatter group of 60 patients.

Complications such as continence, erectile dysfunc-ion, and anastamotic stricture have not changed signif-cantly with these advances. Presumably, therefore, thesere directly related to the EBRT exposure itself and arenlikely to be significantly influenced by additional fac-

igure 2. Cystogram 2 weeks after salvage robotic-assistedadical prostatectomy for external beam radiotherapy failurehowing normal findings.

ors. Short-term incontinence occurs in approximately

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0% of patients and is thought to result from radiation-nduced sphincter dysfunction.10 Long-term, two thirdsf patients require one or fewer pads daily, and artificialphincter implantation remains an effective treatment forhose who require it.10 The continence rates are in-reased in patients who undergo neurovascular bundlereservation, an observation that has been made withoth open and laparoscopic standard RP.11 In some in-tances of SRP, cavernous nerve preservation can bessociated with recovery of potency, particularly whenilateral and in a patient with good preoperative erectileunction. The rate of anastamotic stricture after RT re-ains at 30%, some 5 times greater than that after

tandard RP.10

Most surgeons have only offered open salvage prosta-ectomy to patients after EBRT, in keeping with thencreased technical difficulty of performing the proceduresing a minimally invasive approach. Vallancien et al.,12

n 2003, studied 7 patients who, after EBRT, underwentaparoscopic SRP. They found that the procedure waseasible, with no greater morbidity than an open proce-ure.12 Another group from the United States reportedhe first case of salvage robotic prostatectomy after cryo-herapy failure.13 They had a total operative time of 210inutes and blood loss of 50 mL. The hospital stay was

4 hours, with catheter removal at 7 days and pad-freetatus at 1 month. Only sporadic case reports of SRPsing the da Vinci system have been published. Theorbidity of open vs minimally invasive series could well

e similar whether patients have undergone EBRT orryotherapy. Additional studies are required to clarifyhis further.

ONCLUSIONSn describing this initial case of robotic-assisted SRP, weave shown it to be technically feasible, with minimalorbidity.

cknowledgment. To Christof Kastner, Specialist Registrar,

nd Janette Nichol, Urology Specialist Nurse, Department of

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rology, Guy’s Hospital and King’s College London School ofedicine.

eferences1. Jemal A, Berenson JR, List AF, et al. Cancer statistics. CA Cancer

J Clin. 2005;55:10-30.2. American Society of Therapeutic Radiology and Oncology Con-

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3. Cheung R, Tucker SL, Lee AL, et al. Assessing the impact of analternative biochemical failure definition on radiation dose re-sponse for high-risk prostate cancer treated with external beamradiotherapy. Int J Radiat Oncol Biol Phys. 2005;61:14-19.

4. Kuban DA, Thames AD, Levy LB, et al. Long term multi-institu-tional analysis of stage T1-T2 prostate cancer treated with radio-therapy in the PSA era. Int J Radiat Oncol Biol Phys. 2003;57:915-928.

5. PCA3 urine test may improve prostate cancer diagnosis. Expert RevMol Diagn 2007;7:227-229.

6. Herr HW, Whitmore WF. Significance of prostate biopsies afterradiotherapy for carcinoma of the prostate. Prostate. 2006;3:339-350.

7. Gelet A, Chapelon JY, Poissonnier L, et al. Local recurrence ofprostate cancer after external beam radiotherapy: Early experienceof salvage therapy using high intensity focused ultrasonography.Urology. 2004;63:629-635.

8. Bianco FJ Jr, Scardino PT, Stephenson AJ, et al. Long termoncological results of salvage radical prostatectomy for locally re-current prostate cancer after radiotherapy. Int J Radiat Oncol BiolPhys. 2005;62:448-453.

9. Cheng L, Sebo TJ, Slezak J, et al. Predictors of survival for prostaticcarcinoma treated with salvage radical prostatectomy after radia-tion therapy. Cancer. 1998;83:2164-2171.

0. Stephenson JA, Scardino PT, Bianco FJ Jr, et al. Morbidity andfunctional outcomes of salvage radical prostatectomy for locallyrecurrent cancer after radiation therapy. J Urol. 2004;172:2239-2243.

1. Eastham JA. Does neurovascular bundle preservation at the time ofradical prostatectomy improve urinary continence. Nat Clin PractUrol. 2007;4:138-139.

2. Vallancien G, Gupta R, Cathelineau X, et al. Initial results ofsalvage laparoscopic prostatectomy after radiation failure: Feasibil-ity and prognosis. J Urol. 2003;140:1455-1459.

3. Rodriguez E, Skarecky DW, Ahlering TE, et al. Salvage roboticallyassisted radical prostatectomy with pelvic lymph node dissection

after cryotherapy failure. J Robotic Surg. 2007;1:89-90.

UROLOGY 72 (6), 2008