V4-10: 18 F-Choline PET/CT guided superextended PLND for very high risk PCa. Feasibility and surgical technique
Recent evidences have highlighted the potential benefits of surgical treatment for very high risk and oligometastatic prostate cancer (PCa) patients. _x000D_ In this video we highlight the surgical steps of a 18 fluoro-choline PET-CT guided superextended pelvic lymph node dissection (PLND) during robot assisted radical prostatectomy (RARP) in a 56 yr-old patient with a cT3/N1 Gleason 8 PCa._x000D_
The patient was placed in a steep trendelemburg position and a 6 trocar access, as for a robot assisted radical cystectomy, was performed. Separate package PLND was performed to assess PET-CT accuracy._x000D_ Surgical steps were: identification of inferior mesenteric artery and dissection of nodes around the IMA according to PET-CT; paraaortic and left common iliac node dissection; presacral node dissection; right PLND starting from the common iliac nodes towards the obturator fossa, dissecting the fossa of Marcille; external iliac, internaliliac and obturator node dissection; deflection of the sigma on the right side, and left PLND as described for the right side; extrafascial radical prostatectomy (not shown in the video)._x000D_
Operative time was 190 minutes. Estimated blood loss was 130 mL. Postoperative course was uneventful and the patient was discharged on 3th postopeative day. Pathologist reported a pT3b Gleason score 9 PCa with extraprostatic extension, negative surgical margins and 24 positive nodes out of 40 dissected, confirming nodal metastases in the 4 nodal packages highlighted by the PET-CT scan (paraaortic/left common, distal right common, bilateral obturator). Postoperative 1-mo PSA level was 0.3 ng/mL. Patient started maximum androgen block and 9 mo postoperatively has undetectable PSA levels.
RARP demosntrated to be a feasible and safe procedure for locally advanced PCa. The use of 18-F-choline PET-CT is a rational guide to perform an imaging guided PLND for clinically node positive patients. Reduced invasiveness of this surgery and optimal nodal clearance may contribute to expand indication for surgery in this setting of patients.