Robotic Prostatectomy for Locally Advanced Prostate Cancer

Dr. Yajvender Pratap Singh Rana performs robotic prostatectomy for locally advanced prostate cancer, where the tumour has just breached the prostate capsule, with the aim of cure. In the case he demonstrated, a man with a prostate-specific antigen (PSA) level of 62 received a short course of neoadjuvant hormone therapy, then underwent the operation with an attempt at one-sided nerve sparing and an extended pelvic lymph node dissection.

Dr. Yajvender Pratap Singh Rana is Senior Director - Urology, Uro-Oncology, Andrology and Kidney Transplant at BLK-Max Super Speciality Hospital, New Delhi, India. The robotic radical prostatectomy he demonstrated proceeded in order: posterior dissection of the vasa and seminal vesicles, anterior dissection and control of the dorsal venous complex, division of the bladder neck, release of the prostate with nerve sparing where the tumour allows, a watertight bladder-to-urethra anastomosis and, for higher-risk disease, an extended pelvic lymph node dissection. He walked through each step on video.

Because the patient had locally advanced disease, the case is instructive twice over: it shows how surgery now reaches beyond early cancer, and how the operation changes when the tumour has begun to leave the gland. The second half of this article covers the other operation Dr. Rana singled out as transformed by the robot, partial nephrectomy for kidney tumours. For the wider picture of diagnosis, candidacy and alternatives, see the complete guide to robotic radical prostatectomy.

Robotic prostatectomy for locally advanced prostate cancer: a PSA of 62

A man of 67 came to Dr. Rana with lower urinary tract symptoms. His PSA was 62. He had been having his PSA checked for some time, but chose alternative remedies over conventional treatment and did not see a doctor until it reached that level. On digital rectal examination the prostate was large, hard and nodular.

A PSA of 62, Dr. Rana explained, points to aggressive disease: locally advanced, or possibly metastatic. The work-up was complete:

• MRI of the prostate showed locally advanced disease with an anterior tumour.
• PSMA PET CT, a scan that images a protein expressed on prostate cancer cells, showed that the disease was confined to the prostate and its immediate surroundings, just outside the prostate capsule, with no lymph node involvement and no bone metastases.
• Prostate biopsy confirmed cancer.

Neoadjuvant hormone therapy before prostatectomy

Before operating, Dr. Rana started neoadjuvant androgen deprivation therapy (ADT): hormone treatment, given before surgery, that suppresses testosterone, which drives prostate cancer growth. He used relugolix, an oral gonadotropin-releasing hormone (GnRH) antagonist. Until recently the choice was an injection, either the antagonist degarelix or an agonist such as leuprolide or goserelin.

Relugolix, in his assessment, is now a very good molecule. Tolerance is good, and the patient simply takes a tablet rather than returning for injections. Some patients still prefer injections; this patient chose the tablet. After a few weeks of treatment the prostate had shrunk and the PSA had responded well, and Dr. Rana proceeded to robotic radical prostatectomy. European Association of Urology guidelines do not recommend hormone therapy before radical prostatectomy as routine practice, because it has not been shown to improve survival.

The point he wanted referring doctors to take away: surgery is not confined to men whose PSA is between 4 and 10. Locally advanced and even oligometastatic patients can still benefit from an operation aimed at cure.

Robotic prostatectomy technique: the eight steps

Dr. Rana's operation ran in eight steps, from the seminal vesicles behind the prostate to the lymph nodes along the pelvic side wall.

1. Posterior dissection

The operation began behind the prostate. Dr. Rana dissected the vas deferens, the tube that carries sperm, on each side, then the seminal vesicles, the paired glands that sit behind the prostate and are removed with it. The artery to the seminal vesicle was dissected and divided. Both vasa and both seminal vesicles were freed in this way.

2. Anterior dissection and the endopelvic fascia

Attention then moved to the front. The bladder was dropped by incising the peritoneal flap and entering the anterior plane, the space in front of the bladder and prostate. The endopelvic fascia, the sheet of tissue covering the side walls of the prostate, was opened and dissected down towards the level of the urethra and the dorsal venous complex.

3. Controlling the dorsal venous complex

The dorsal venous complex (DVC) is a cluster of veins lying over the front of the urethra at the apex of the prostate. It must be stitched to prevent bleeding. Dr. Rana paused the video here to point out the angle: the stitch is placed very deep in the pelvis, at a steep angle. By laparoscopy this was a very difficult and challenging stitch. With the robot it can be placed conveniently and haemostasis secured.

4. Dividing the bladder neck

Next the junction between prostate and bladder, the bladder neck, was divided in a bloodless plane, separating the bladder from the prostate. Once the urethra was opened, the catheter was lifted out of the way. The posterior bladder wall was then dissected, which brought the surgeon down to the posterior plane, from where the vasa and seminal vesicles freed earlier were delivered.

5. Nerve sparing

The neurovascular bundles, which carry the nerves responsible for erection, run along each side of the prostate. In early disease, Dr. Rana noted, the surgeon sees a clean, smooth picture of the bundles. In this locally advanced case the fat planes were heavily adherent, the expected consequence of tumour close to the capsule. Even so, he attempted to preserve the neurovascular bundle on one side. How nerve sparing translates into recovery of erections is the subject of the article on erectile function and continence after robotic prostatectomy.

6. The vesicourethral anastomosis

With the prostate removed, the bladder is joined to the urethra over a Foley catheter. This is the vesicourethral anastomosis. In the video the result was almost bladder-neck-preserving, and Dr. Rana predicted good continence for this patient because of it. Further stitches completed the join.

7. The leak test

Saline was then run into the bladder to test the anastomosis. There was no leak. A watertight anastomosis is what allows the catheter to come out early: in this situation Dr. Rana removes it with very good confidence after 7 to 10 days.

8. Extended pelvic lymph node dissection

Because the disease was locally advanced, an extended lymph node dissection was performed. The lymph node packet was removed from along the external iliac artery and the internal iliac artery, down into the obturator fossa, with the obturator nerve and obturator artery identified. Removing these nodes stages the disease accurately and clears tissue where cancer may have spread.

Why the robot matters most in two operations

Dr. Rana singled out two operations in which the robot is really advantageous for the patient: radical prostatectomy and partial nephrectomy. The robot can be used for many urology operations, including reconstructions such as pyeloplasty, stone removal by pyelolithotomy, and radical cystectomy with a neobladder or ileal conduit.

Robotic partial nephrectomy for kidney tumours

Partial nephrectomy removes the tumour and a margin of normal tissue while leaving the rest of the kidney working. Its purpose is to preserve nephrons, the filtering units of the kidney, and the robot, Dr. Rana said, makes that preservation possible.

Bilateral kidney tumours: save at least one kidney

When tumours affect both kidneys, Dr. Rana's principle is to perform robotic partial nephrectomy on both sides if feasible. If it is not feasible on both, at least one kidney must be saved by partial nephrectomy; otherwise the patient ends up on dialysis. Age is no bar: he showed the scans of a young man of only 25 with a large tumour in the right kidney and a tumour in the left kidney as well.

Repeat partial nephrectomy in the same kidney

A second patient, operated on twice in the same kidney, illustrated why nephron preservation matters over a lifetime. Dr. Rana performed his first partial nephrectomy about seven years earlier, removing a lower-pole tumour. Some five years later a new, unrelated tumour developed in the middle portion of the same kidney, and he performed a second partial nephrectomy. Roughly 30 to 35% of that kidney, from its lower part, has been lost, but the upper pole was saved. Dr. Rana put the chance of a new kidney tumour developing in the same kidney or the other kidney at about 4%, which is why every preserved nephron counts.

How robotic partial nephrectomy is performed

In the video Dr. Rana demonstrated:

1. Dissection of the renal hilum, where the main vessels enter the kidney, isolating the renal artery and vein so that blood flow can be controlled.
2. Intraoperative ultrasound to localise the tumour. Here it was almost invisible on the surface, a small bulge only. Without ultrasound the surgeon cannot judge how large the tumour is or where to begin the dissection.
3. Excision of the tumour, lifted out whole from what had looked like a very difficult location.
4. Renorrhaphy in two layers, the stitching that closes the kidney defect and controls bleeding, followed by removal of the clamps.

Metastatic kidney cancer with IVC thrombus: surgery or drugs

In Dr. Rana's answer, a kidney tumour extending into the inferior vena cava is still treated with surgery, but once there are multiple distant metastases the right course is biopsy and systemic treatment. The same session included this counterpoint. A doctor described a woman in her forties with haematuria and flank pain, found to have a renal mass, most likely renal cell carcinoma (RCC), with tumour thrombus in the renal vein extending into the inferior vena cava (IVC), and metastases in the liver and lungs.

Dr. Rana's answer separated two situations:

• Tumour thrombus alone is still surgical. A kidney tumour extending into the IVC is considered localised or locally advanced, and his team has performed many nephrectomies with IVC thrombectomy.
• Multiple distant metastases are not. With metastases in the liver and elsewhere, patients do not do well after surgery. The right course is a biopsy of the kidney to establish the subtype (clear cell, chromophobe, papillary or another malignancy), followed by systemic treatment.

RCC is resistant to conventional chemotherapy, but it responds to other drugs. Dr. Rana's first choice is immunotherapy, given first-line as a combination such as nivolumab with ipilimumab or pembrolizumab with axitinib, which guidelines increasingly place at the centre of treatment for advanced and metastatic disease and whose benefit he has seen personally in his patients. Where immunotherapy is not available, tyrosine kinase inhibitors (TKIs) such as sunitinib or pazopanib are the alternative. The patient and family should be given a guarded prognosis. The full exchange is on the Live Discussion page.

Approximate costs for international patients are set out on the robotic radical prostatectomy cost page and the nephrectomy cost page. Systemic treatment for prostate cancer that has spread is covered in the article on advanced prostate cancer.