Presentation Authors: Akbar Ashrafi*, Andre Luis de Castro Abreu, Alessandro Tafuri, Giovanni Cacciamani, Aliasger Shakir, Matthew Winter, Daniel Park, Prakash Gill, Inderbir Gill, Alhambra, CA
Introduction: Pelvic lymph node dissection (PLND) remains the gold standard for nodal staging in prostate cancer (PCa). Radical prostatectomy for intermediate-high risk prostate cancer (PCa) routinely incorporates regional lymphadenectomy. Current guidelines recommend PLND during radical prostatectomy in men at risk of lymph node involvement (LNI). However, during high-intensity focused ultrasound (HIFU) ablation for similar risk PCa, the regional lymph nodes remain untreated. To address this issue, we explored concomitant robotic lymphadenectomy (rLND) during focal hemi-gland HIFU (fHIFU) for intermediate-high risk PCa.
Methods: Ten highly-selected men with unilateral Gleason Grade (GG) > 1 PCa (90% had GG 3-5 PCa; 50% had recurrent PCa) were identified from our IRB-approved database (HS-18-00498) between 07/2016 and 09/2018. LND was indicated for any recurrent PCa or >5% risk of lymph node invasion (LNI) for primary PCa on validated nomograms. Patients had mpMRI and 12-core systematic and targeted fusion prostate biopsy, and work-up to exclude bony or visceral metastasis. We evaluated feasibility, safety and perioperative outcomes. Complications were recorded up to 30 days using Clavien Classification System.
Results: All patients had unilateral Grade Group (GG) 2 or higher disease; 9 patients (90%) had unilateral GG 3-5 disease. No patients had > GG 1 PCa in the contralateral lobe. Five patients had primary and 5 had recurrent PCa. Median LNI risk was 11%; no patient had bony/visceral metastasis. Concomitant fHIFU and rLND was technically successful in all patients. Median total operating time was 5.2 hours, robotic console time 2 hours, blood loss 50 ml and hospital stay 1 day. Median number of nodes resected was 19 (range, 8-93); 3 patients (30%) had positive nodes. Four patients had minor (Clavien 1-2) complications. At median follow-up of 5 months (1-24), median PSA reduction was 82%. Median time-to-nadir PSA was 3 months. Continence and potency status remained unchanged from baseline.
Conclusions: This initial proof-of-concept study demonstrates the safety and feasibility of concomitant focal HIFU with robotic LND. We believe the management of regional nodes should be dictated by the existent risk of LNI, not the treatment modality selected for the prostate primary. Thus, if focal therapy is to be considered for select men with unilateral intermediate-high risk PCa, management of potential nodal metastasis should be considered.