Simultaneous robot-assisted abdominoperineal rectal resection and Retzius-sparing prostatectomy for synchronous rectal and prostate cancer - a video vignette

Intersphincteric abdominoperineal resection with radical en bloc prostatectomy for synchronous or locally advanced rectal or prostate cancer

INTRODUCTION

For patients with locally advanced rectal cancer invading the prostate or prostate cancer invading the rectum a negative resection margin (R0) is the most important criterion to predict local recurrence and disease-free survival. Following neoadjuvant treatment (when indicated), pelvic exenteration is often the surgical treatment of choice in these patients, involving en bloc excision of the rectum, prostate, and bladder to ensure clear resection margins and resulting in a colostomy and ileal conduit. The surgery is most commonly performed by laparotomy. We describe an alternative less invasive option for synchronous or locally advanced rectal or prostate cancer in the form of a laparoscopic (or robotic assisted) intersphincteric abdominoperineal resection (APR) with en bloc prostatectomy and urinary reconstruction in selected patients.

METHODS

Patients with synchronous rectal and prostate disease or locally advanced rectal and/or prostate cancer undergoing minimally invasive intersphincteric APR with en bloc prostatectomy with urinary reconstruction were retrospectively analyzed. The primary endpoint was the proportion of negative resection margins. Secondary endpoints included complications and disease recurrence.

RESULTS

Eleven consecutive patients were identified. All patients had negative resection margins and there were no patients with disease recurrence of either rectal or prostate cancer after a median follow-up of 26 months (IQR 63). There were no same admission reoperations, two patients with a postoperative ileus and two patients with an urinary leak, of which one had a delayed leak at 7 months which was repaired. Urinary incontinence rates varied, but only one patient was referred for insertion of an artificial urinary sphincter.

CONCLUSION

Intersphincteric minimal invasive APR with en bloc prostatectomy is a feasible alternative to complete pelvic exenteration in selected patients with synchronous or locally advanced rectal and/or prostate cancer.

Simultaneous robotic-assisted prostatectomy and rectal resection: a systematic review

Prostate cancer (PC) and rectal cancer (RC) are common and can require complex management, especially when presenting synchronously or with invasive characteristics. Robotic surgery has emerged as a viable option for managing these challenging cases; however, the outcomes are yet to be summarised or compared to traditional approaches. This systematic review aims to evaluate the feasibility, oncological outcomes, and functional results of simultaneous robotic-assisted resections of the prostate and rectum. Following prior protocol registration (PROSPERO: CRD42023449872) and according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, we conducted a systematic search across multiple databases, selecting studies that involved simultaneous bladder-sparing robotic-assisted prostatectomy and rectal resection. The Joanna Briggs Institute tool was used for risk of bias assessment. Data on patient demographics, treatment details, post-operative course, and functional and oncological outcomes were extracted and analysed. From 1357 identified records, 25 studies met our inclusion criteria resulting in 45 cases/patients. The median patient age was 62 years. Diverse treatment backgrounds and outcome definitions were recorded. Median operative time was 548 min and median estimated blood loss was 450 mL. The overall complication rate was 44.4%, with major complications (Clavien-Dindo III) occurring in 17.8% of cases. Surgical margins were negative in 92.6% of cases. Continence recovery occurred for most (78.6%) of the cases reporting on urinary function. Simultaneous robotic-assisted prostatectomy and rectal resection appears to be a feasible, safe and oncologically effective approach with satisfactory oncological and functional outcomes for managing patients with synchronous or invasive PC and RC.