CASE REPORT Robot Assisted Radical Prostatectomy in A Patient with Previous Abdominoperineal Resection and Pelvic External Beam Radiation Therapy Cem Basatac*, Haluk Akpinar Keywords: challenging conditions; prostate cancer; minimally invasive surgery; robot. Though previous major abdominal surgery and pelvic irradiation may be a significant drawback of subsequent laparoscopic procedure, technological advances such as better visualization and more controlled finer movements of robotic arms allowing better dissection in robotic-assisted laparoscopic surgery may reduce some of these chal- lenges. However, limited data are available on the effect and safety of robotic surgery in these patients. The aim of this case report is to present efficacy and safety of robot assisted radical prostatectomy in a patient who has rectal and concurrent prostate cancer with the history of abdominoperineal resection, pelvic irradiation and adjuvant chemotherapy. Department of Urology, Istanbul Bilim University, School of Medicine, Istanbul, Turkey. *Correspondence: Istanbul Bilim University, Department of Urology, Istanbul/Turkey Phone: +90 (212) 213 64 86. Facsimile number: +90 (212) 272 34 61. Email: cembasatac@gmail.com. Received March & Accepted December 2017 INTRODUCTION Robotic assisted radical prostatectomy (RARP) has been recently introduced for the treatment of localized prostate cancer and rapidly gained acceptance in worldwide. Many reports have been established that robotic surgery is not inferior when compared with other conventional approaches in terms of surgical, functional and oncologic outcomes(1-2). As with open radical prostatectomy, there are no anatomic contraindications for RARP. However, there are preoperatively identified factors considered as potentially challenging that have been described in the literature(3-5). The most important factors among these are previous pelvic external beam radiation therapy [EBRT] and major abdominal surgery. These factors can significantly affect operative outcomes because of severe adhesions and obliterated tissue plans. The aim of this case report is to present the advantages of RARP in patient with rectal and concurrent prostate cancer with the history of abdominoperineal resection (APR), EBRT and adju- vant chemotherapy. Figure 1. CT-Guided suprapubic biopsy was done due to closed anal verge secondary to pre- vious surgery. Case Report 56 Vol 15 No 03 May-June 2018 57 CASE REPORT A 74-year-old male patient admitted to our hospital with elevated PSA at 4.85ng/mL. In his past history, the patient had received APR, EBRT and adjuvant chemo- therapy for rectal cancer at 2013. There were no find- ings suggestive of local recurrence and distance me- tastases of rectal cancer according to 18 FDG PET/CT imaging at the last follow up. A multiparametric mag- netic resonance imaging showed multiple PI-RADS 4 lesions involving both lobes of prostate but digital rectal examination and TRUS guided biopsy were not possible due to closed anal verge secondary to prior sur- gical resection. Computerized tomography guided su- prapubic biopsy revealed prostate adenocarcinoma with a Gleason score of 4+4 (Figure 1). Definitive surgical treatment with robotic assistance was desired by the pa- tient. Therefore, we obtained informed consent in order to perform RARP. Bowel preparation was done day before surgery and co- lostomy site was covered with lobanTM film (3M, St, Paul, MN) to prevent contamination. A 2 mm transvers skin incision was made 3 cm below from the left costal margin on the midclavicular line as the primary punc- ture site, known as Palmer’s point. Through this inci- sion, a Veress needle was inserted to create pneumop- eritoneum. Since high probability of the bowel injury due to intraperitoneal adhesions, first 5 mm trocar was inserted at the 3 cm below from the right costal mar- gin on the midclavicular line. Extensive intraperitoneal adhesions were completely removed from the surgical field and colostomy site by using with 4 mm laparo- scopic scissor. Afterwards, one 12 mm and three 8 mm trocars were inserted under direct vision. Left 8 mm trocar was placed on 3 cm below and medial from the normal location due to end-colostomy and only one 12 mm assistant port was used since there was not enough space for other trocar (Figure 2). Total operation time and console time including bilat- eral lymph node dissection were measured as 181 and 135 minutes, respectively. Blood loss was 150 ml. and no intraoperative complication was noted. However, length of stay was 8 days due to postoperative subileus- that resolved spontaneously. Total urinary control was achieved at postoperative 3rd months. Severe erectile dysfunction was observed since neurovascular bundles were not spared. PSA values were measured at 3 and 6th months as < 0, 01 ng/ml and surgical margins were emphasized as negative. DISCUSSION Previous major abdominal surgery and radiation ther- apy are not an absolute contraindication for RARP. However, these factors cause severe intestinal adhe- sions which may complicate port placement and require extensive surgical adhesiolysis. Furthermore, radiation induced tissue adhesion can make the identification of the plans challenging especially during seminal vesi- cle and endopelvic fascia dissection. First radical ret- ropubic prostatectomy series in the setting of previous pelvic radiation therapy for non-prostate malignancies was reported by Materson et al. They were successful in doing RP in their 9 patients but higher rates of in- continence, voiding difficulty, bladder neck contracture and erectile dysfunction were reported(6). In addition to this, Yang et al. compared surgical, oncologic and functional outcomes of laparoscopic radical prostatec- tomy (LRP) in patients with and without transurethral resection of prostate (TUR-P). The authors concluded that LRP is feasible but challenging after TUR-P with greater blood loss, longer operation times, higher com- plication rates and worst short term continence out- comes(7). Robotic systems have several advantages over conventional laparoscopy in order to overcome some of these challenges. The advantages of robotic surgery like three-dimensional visualization, seven degree of free- dom in movement and avoiding physiologic tremor can facilitate urethrovesical anastomosis and provide con- veniences especially in the posterior dissection in the narrow small pelvis(8). During RARP in patients with previous major abdom- inal surgery, it is crucial to carried out a wide laparo- scopic adhesiolysis before docking the robot since the position of the trocar sites cannot be changed without undocking the robot. Boylu et al. reported a novel tech- nique to lyse adhesions by using a teaching laparoscope with an offset eye piece and working channel to allow visualization of the operative field with concomitant passage of laparoscopic scissor(9). On the other hand, Rajih et al. described a mini-laparotomy technique in order to lyse extensive peritoneal adhesions which fa- cilitates subsequent minimally invasive surgery where laparoscopic adhesiolysis is difficult and unsafe. In this technique, a midline infraumblical incision was per- formed through a 7-10 cm and then, adhesions were di- vided sharply under direct vision(10). In the present case, we encountered severe and dense peritoneal adhesions due to previous APR with supra and infraumblical inci- sion and EBRT. Primarily, we chose Palmer’s point in order to provide pneumoperitoneum because an abdom- inopelvic CT demonstrated no evidence of suspicious bowel adhesions on the left upper quadrant(11). Classic closed technique with Veress needle was used in order to create pneumoperitoneum. Afterwards, meticulous adhesiolysis was performed by using laparoscopic scis- sor via a 5 mm additional trocar inserted on the right Figure 2. Postoperative aspect of port placements. Robotic radical prostatectomy under challenging conditions-Cem et al. upper quadrant to subsequently allow safe placement of additional robotic trocars. The main challenge for RARP in patient with prior APR is the port site limitations due to the end-colos- tomy. Robotic left working arm had to be placed 3 cm caudally and medially from the colostomy in order to keep enough distance between camera port and 12 mm assistant port. Care should be taken not to injure bowel segments at this stage. Therefore, peritoneal adhesions should be completely removed around the colostomy site so as to provide safe change of the robotic instru- ments, if needed. To the best of our knowledge, this is the second case report related to RARP in patient with the history of APR, EBRT and adjuvant chemotherapy. First case was reported at 2009 by Ham et al.(12) Yet, the authors distinctly used Hasson technique to cre- ate pnömoperitoneum and fourth robotic arm was not placed due to inadequate surgical space. They also did not perform LND because of severe adhesions second- ary to prior surgery. On the final pathology of their case, surgical margin was negative and total urinary control was achieved at the first postoperative month. Finally, the authors concluded that history of APR and EBRT are not contraindication for RARP although there is a technical difficulty. CONCLUSIONS Although it is seen as a challenging procedure due to severe adhesions, prior APR and EBRT should not be considered as a contraindication for RARP since robotic surgery provides many advantages to the surgeon such as tremor reduction and magnified three-dimensional visualization that affect directly to surgical outcomes. CONFLICT OF INTEREST The authors report no conflict of interest. REFERENCES 1. Seo HJ, Lee NR, Son SK, Kim DK, Rha KH, Lee SH. Comparison of robot-assisted radical prostatectomy and open radical prostatectomy outcomes: A systematic review and meta- analysis. Yonsei Med J. 2016; 57:1165-77. 2. Allan C, Ilic D. Laparoscopic versus robotic- assisted radical prostatectomy for the treatment of localised prostate cancer: A systematic review. Urol Int. 2016; 96:373-78. 3. Parsons JK, Jarrett TJ, Chow GK, Kavoussi LR. 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