V11-08: Super-extended Robotic-Assisted Radical Prostatectomy for Locally Advanced Prostate Cancer
Robotic-assisted radical prostatectomy (RARP) is an effective procedure for patients with high-risk disease, but positive margin rates need to be improved. In this video we describe our technique of super-extended RARP in patients with posterior T3a or T3b prostate cancer at multiparametric MRI, which increases the oncological safety margin.
Two cases are presented, using the Da Vinci Xi robotic system at a tertiary care referral Center. The first is a 68-year-old man with PSA of 17 ng/ml, cT3 on the right side at digital rectal examination (DRE), an MRI showing PIRADS 5 in the right seminal vesicle where there was a Gleason 4+5 at biopsy. Gleason 4+3 was present throughout the right side of the prostate. A super-extended RARP with unilateral right Denonvilliers’ fascia (DVF) resection and extended lymph node dissection was performed. The second case is a 73-year-old man with PSA of 38 ng/ml, bilateral cT3 on DRE, an MRI showing PI-RADS 5 lesions in both seminal vesicles where there was a Gleason 5+3 at biopsy. A super-extended RARP with bilateral DVF resection and extended lymph node dissection was performed. After identification and isolation of the vas deferens behind the prostate, the peritoneum of the rectovesical pouch was opened, allowing us to perform an extrafascial prostatectomy, where DVF and some perirectal fat are dissected free so that they remain on the posterior surface of the seminal vesicles. The dissection is carried forwards to the anterior face of the rectum, continually pushing the perirectal fat and DVF upwards with the specimen. Thereafter, an extrafascial dissection is subsequently carried out laterally to the levator ani fascia. In the unilateral DVF resection, the seminal vesicle on the side without tumour burden was released in a standard fashion leaving DVF attached to the rectum.
For the first case (unilateral DVF resection), final pathology showed Gleason 4+3, pT3bN0R0. 28 nodes were excised. The second case (bilateral DVF resection) demonstrated Gleason 4+4, pT3bN1R0, with 1 out of 41 positive node. Total operative time was 150 and 200 min for the unilateral and bilateral DVF resection, respectively. The length of stay was 3 days for both procedures. The estimated blood loss was 150 and 200 ml for the first and second cases, respectively. The post-operative periods were uneventful, and the bladder catheter was removed on POD day 2 in both cases
Super-extended RARP is feasible in patients with posterior T3a or T3b prostate cancer. Long-term follow up data is needed to demonstrate that it is associate with improved oncological outcomes