Presentation Authors: Fikret Onol*, Seetharam Bhat, Travis Rogers, Cathy Jenson, Shannon Roof, Vipul Patel, Celebration, FL
Introduction: Salvage robot-assisted laparoscopic prostatectomy (sRARP) is a demanding procedure due to significant alterations in anatomical landmarks and loss of tissue planes. In this video, we present the challenges associated with different primary treatments and describe key points in their management.
Methods: Between 2008 and 2018, 121 patients underwent sRALP by a single surgeon. Ninety patients had received radiation (EBRT: 47, IMRT: 14, proton beam: 3, brachytherapy: 22, EBRT+brachy: 14) and 31 had received focal therapy (cryotherapy: 18, HIFU: 9, microwave/electroporation: 4) as primary treatment. Difficulties caused by different primary therapies at each surgical step were identified and key points in their management were presented.
Results: Endopelvic fascia (EPF) dissection: Ipsilateral pelvic side-wall fibrosis and bleeding from vessels obscured by scarring were common after cryoablation. Opening the EPF at the prostate base where the space between the prostate and the levators is least vascular and dissection away from the prostate capsule towards the apex facilitated this dissection. Apical dissection around the sphincter was typically difficult after brachytherapy due to inflammation caused by misplaced seeds. Bladder neck (BN) dissection: In cases with HIFU, the prostate was atrophic and fused anteriorly behind the pubic tubercle. In such cases, opening the anterior BN provided better identification of the anatomy followed by antegrade prostatectomy.Posterior dissection: IMRT and proton beam were noted to cause more extensive fibrosis in the pelvis. In such cases, identification of the correct plane for posterior dissection was especially difficult due to lack of prerectal fat and &[prime]tenting&[prime] of the rectum. We have used the instant toggling feature of DaVinci Xi robot (180 degrees upward rotation of the 30-degree camera) to facilitate visualization of the posterior plane and careful cold dissection.Vesicourethral anastomosis (VUA): Loss of tissue vascularization after EBRT and proton beam radiation adversely affects VUA vitality and leads to anastomotic dehiscence or leaks. In our experience, use of an acellular and resorbable scaffold graft to reinforce base of the VUA resulted in decreased leak rates and catheterization times.
Conclusions: sRALP should be performed by experienced surgeons due to lack of tissue planes and anatomical landmarks. The surgeon should be familiar with challenges specific to different primary therapies and with key points in their management.