Simultaneous robotic low anterior resection and prostatectomy for adenocarcinoma of rectum and prostate: initial case report

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.

Salvage robot-assisted radical prostatectomy with pelvic lymph node dissection for radiorecurrent prostate cancer in a patient with a previous history of rectal cancer surgery

Introduction

Severe adhesions render salvage robot-assisted radical prostatectomy challenging in the treatment of patients with prostate cancer who have previously undergone colorectal cancer surgery.

Case presentation

A 76-year-old Japanese man who had previously undergone low anterior resection for rectal cancer presented with an elevated prostate-specific antigen level, indicating a recurrence of prostate cancer that had been treated with intensity-modulated radiation and androgen deprivation therapies. During the salvage robot-assisted radical prostatectomy with pelvic lymph node dissection, severe adhesions were noted between the posterior aspect of the prostate and the intestine. The adhesions were successfully dissected under digital rectal examination and transrectal ultrasound guidance.

Conclusion

Salvage robot-assisted radical prostatectomy after rectal cancer can be challenging. The use of transrectal ultrasound and digital rectal examination can facilitate the procedure. Screening for prostate cancer prior to colorectal cancer surgery could potentially allow for simultaneous resections.

Robot-assisted radical prostatectomy in patient with previous intersphincteric resection for rectal cancer

Introduction

There are often opportunities to consider treatment strategies for synchronous or metachronous prostate cancer with colorectal cancer. Performing robot-assisted radical prostatectomy for prostate cancer following previous rectal cancer surgery in cases involving anal-preserving surgeries such as low anterior resection or intersphincteric resection can be challenging because of the possibility of adhesions.

Case presentation

A 74-year-old man who had undergone laparoscopic intersphincteric resection for rectal cancer was diagnosed with prostate cancer. The patient desired to undergo robot-assisted radical prostatectomy. During surgery, we observed the absence of Denonvillier's fascia on the dorsal surface of the prostate, the intestinal anastomosis was distal to the vesicourethral anastomosis, and the rectum was replaced with a peristaltic sigmoid colon with minimal adhesions.

Conclusion

Periprostatic conditions vary depending on previous rectal surgical approaches. It is crucial to confirm the previous surgical approach for rectal cancer when performing robot-assisted radical prostatectomy following rectal cancer surgery.

Prostate Cancer Diagnosis, Treatment and Outcomes in Patients with Previous or Synchronous Colorectal Cancer: A Systematic Review of Published Evidence

The management of patients with prostate cancer (PCa) and previous or synchronous colorectal cancer (CRC) represents a challenging issue. A systematic review was performed in May 2022 to summarize available evidence about the diagnosis, management, and outcomes of these patients. Twenty-seven studies involving 252 patients were identified. Overall, 163 (64.7%) and 89 (35.3%) patients had synchronous and metachronous PCa and CRC, respectively. In patients with synchronous diseases, PCa treatment involved active surveillance in 1 patient, radical prostatectomy (RP) in 36 patients, radiotherapy (RT) in 60 patients, RP plus RT in 1 patient, proton beam therapy in 1 patient, and cryoablation in 1 patient. In patients with previous CRC treatment, prostate biopsy was mostly performed by transrectal approach (n = 24). The trans-perineal and suprapubic approaches were adopted in 12 and 6 cases, respectively. Surgical PCa treatment in these cases involved endoscopic extraperitoneal RP, robot-assisted RP, and not otherwise specified RP in 30, 15, and 2 cases, respectively. Biochemical recurrence rates ranged from 20% to 28%. Non-surgical PCa treatment options included brachytherapy, RT plus androgen deprivation therapy, and RT alone in 23, 2 and 4 patients, respectively. PCa specific survival was reported by one study and was 100%.

Combined robotic radical prostatectomy and laparoscopic proctectomy for synchronous prostate and rectal cancer

Prostatic adenocarcinoma is the second most common cause of cancer related mortality in men. Robotic-assisted laparoscopic prostatectomy represents a standard treatment option for localized disease. We present a case of a 63-year-old male with synchronous presentation of prostate and rectal cancer treated with combined robotic prostatectomy (RALP) and low anterior resection (LAR). Interestingly, a mesorectal lymph node contained metastatic prostate cancer.

The clinical impact of robot-assisted laparoscopic rectal cancer surgery associated with robot-assisted radical prostatectomy

INTRODUCTION

Robot-assisted laparoscopic surgery has been performed in various fields, especially in the pelvic cavity. However, little is known about the utility of robot-assisted laparoscopic rectal cancer surgery associated with robot-assisted radical prostatectomy (RARP). We herein report the clinical impact of robot-assisted laparoscopic rectal cancer surgery associated with RARP.

METHODS

We experienced five cases of robot-assisted laparoscopic rectal cancer surgery associated with RARP. One involved robot-assisted laparoscopic abdominoperineal resection with en bloc prostatectomy for T4b rectal cancer, and one involved robot-assisted laparoscopic intersphincteric resection combined with RARP for synchronous rectal and prostate cancer. The remaining three involved robot-assisted laparoscopic low anterior resection (RaLAR) after RARP. For robot-assisted laparoscopic rectal cancer surgery, the da Vinci Xi surgical system was used.

RESULTS

We could perform planned robotic rectal cancer surgery in all cases. The median operation time was 529 min (373-793 min), and the median blood loss was 307 ml (32-1191 ml). No patients required any transfusion in the intra-operative or immediate peri-operative period. The circumferential resection margin was negative in all cases. There were no complications of grade ≥III according to the Clavien-Dindo classification and no conversions to conventional laparoscopic or open surgery.

CONCLUSION

Robot-assisted laparoscopic surgery associated with RARP is feasible in patients with rectal cancer. The long-term surgical outcomes remain to be further evaluated.

Full robotic multivisceral resections: the Modena experience and literature review

The robotic platform is becoming a multidisciplinary tool, versatile, and suitable for multiple procedures. Combined multivisceral resections may represent an alternative to sequential procedures with a potential favorable impact on postoperative morbidity, and on the timing of administration of adjuvant chemotherapy. We herein present our initial experience with full robotic multivisceral resections, and a review of the literature available. Between January 2018 and April 2020, 11 patients underwent multivisceral full robotic abdominal surgery: 4 patients presented with two synchronous tumors, 4 with primary cancer associated with a benign condition and 3 cases involved deep infiltrating endometriosis. Surgical teams enrolled were: General Surgery, Urology and Gynecology. A systematic bibliographic research up to April 2020 was conducted in PubMed. 4 colorectal resections combined with partial or radical nephrectomy were performed, as well as 2 right colectomies in combination with right adrenalectomy and gastric banding removal, 2 radical prostatectomies with Nissen Fundoplication and abdominal wall hernia repair, and 3 resections of deep pelvic endometriosis with colorectal involvement. Mean total operative time was 367 min. No intraoperative complication or conversion to open was registered. Overall postoperative complication rate was 18.2%. 26 papers were included in the review (10 case series and 16 case reports) with a total of 156 combined multivisceral robotic procedures recorded. Robotic combined multivisceral resections proved to be safe and feasible when performed in high volume centers by expert surgeons. The heterogeneity of reports does not allow for a standardization of the procedure. Further studies and accumulation of experience are needed.

Simultaneous robot-assisted surgery for rectal cancer and prostatic lesions

Robotic surgery has become prevalent in many departments all over the world because of its usefulness. It is used in many cases, as well as in gastrointestinal surgery, which treats the rectum as pelvic surgery, urology and gynecology. We experienced two cases of joint surgery, with urology as pelvic surgery. The patient underwent robot-assisted low anterior resection, combined prostate resection and ileostomy for prostate invasion of rectal cancer. He was discharged without any complications. Robotic surgery was considered to be useful in surgery to manipulate the same area. In addition, it was considered that smoother and safer surgical procedure could be possible by conducting preoperative meetings with the participating departments.

First cases of combined full robotic partial nephrectomy and colorectal resections: Results and new perspectives

Background

Nowadays the robotic platform is widespread in general surgery, urology, and gynecology. Combined surgery may represent an alternative to sequential procedures and it allows the treatment, at the same time, of coexisting lesions; in this perspective, full‐robotic multiorgan surgery is starting to gain interest from surgeons worldwide.

Methods

Between April and June 2019, two patients presenting with synchronous colorectal and kidney cancers underwent, respectively, full‐robotic right colectomy with right partial nephrectomy and anterior rectal resection with left partial nephrectomy. Surgeries were performed by both the general surgery and urology team.

Results

No intraoperative complications were registered and the postoperative course was uneventful in both cases.

Conclusions

Combined multiple organ surgery with full robotic technique is safe and offers oncological adequate results. A multi‐team surgical pre‐planning is mandatory to reduce invasiveness and operative time. To the best of our knowledge, these are the first reports of full robotic partial nephrectomy combined with colorectal procedures.

Multi-Institutional Analysis of Synchronous Prostate and Rectosigmoid Cancers

Purpose: To perform a multi-institutional analysis of patients with synchronous prostate and rectosigmoid cancers.

Materials and Methods: A retrospective review of Duke University and Durham Veterans Affairs Medical Center records was performed for men with both prostate and rectosigmoid adenocarcinomas from 1988 to 2017. Synchronous presentation was defined as symptoms, diagnosis, or treatment of both cancers within 12 months of each other. The primary study endpoint was overall survival. Univariate and multivariable Cox regression was performed.

Results: Among 31,883 men with prostate cancer, 330 (1%) also had rectosigmoid cancer and 54 (16%) of these were synchronous. Prostate cancer was more commonly the initial diagnosis (59%). Fifteen (28%) underwent prostatectomy or radiotherapy before an established diagnosis of rectosigmoid cancer. Stage I, II–III, or IV rectosigmoid cancer was present in 26, 57, and 17% of men, respectively. At a median follow-up of 43 months, there were 18 deaths due rectosigmoid cancer and two deaths due to prostate cancer. Crude late grade ≥3 toxicities include nine (17%) gastrointestinal and six (11%) genitourinary. Two anastomotic leaks following low anterior resection occurred in men who received a neoadjuvant radiotherapy prostate dose of 70.6–76.4 Gy. Rectosigmoid cancer stages II–III (HR 4.3, p = 0.02) and IV (HR 16, p < 0.01) as well as stage IV prostate cancer (HR 31, p < 0.01) were associated with overall survival on multivariable analysis.

Conclusions: Synchronous rectosigmoid cancer is a greater contributor to mortality than prostate cancer. Men aged ≥45 with localized prostate cancer should undergo colorectal cancer screening prior to treatment to evaluate for synchronous rectosigmoid cancer.