Lymph node recurrence after radical prostatectomy (RP) is usually managed with androgen-deprivation therapy (ADT). Despite the absence of strong supporting evidences, salvage lymph node dissection (sLND) has been proposed as an alternative treatment option. In most of the available series, an open approach was chosen. Persuaded that the robotic system may have a positive impact on this technically demanding procedure, we present our series of robot-assisted sLND (RASND).
We retrospectively evaluated all the patients treated with RASND at our center from 2011 onwards. The surgical approach was offered to only-nodal oligometastatic (≤ 3 suspected nodes) patients, as documented by preoperative positron emission tomography/computed tomography (PET/TC) scan. Surgery was performed by a single surgeon (VP), using a DaVinci Si system. All the lymphatic stations up to the one affected by the radiologically identified recurrence were cleared.
Ten patients were included in the study, overall. Their median age was 73 years (IQR: 69/74) and mean prostate specific antigen (PSA) level before RASND was 2.18±1.9 ng/ml. According to the preoperative Cho-PET/TC, nodal recurrences were localized in the pelvis in 9/10 patients; only one patient (shown in the video) was diagnosed with a suspected node in the retroperitoneum.
A median of 6 nodes (IQR: 3.5/17) were retrieved and 2 (IQR: 1/3) were found affected by prostate cancer (PCa) recurrence at pathological examination. Mean PSA after RASND was 1.18±1.3 ng/ml. Three patients (33%) overall reported a biochemical response (PSA < 0.02 ng/ml). Among these, one received ADT 12 months after sLND because of a further raise of the antigen; the other two are still free from recurrence 24 and 40 months after surgery, respectively.
No Clavien ≥ 3 complications were reported. One intraoperative vessel injury occurred and was easily managed without need for conversion. Interestingly, the patient reported in the video had 19 nodes removed and 3 were positive for PCa recurrence. Post-RASND PSA was 1 ng/ml. A prostate specific membrane antigen-PET/TC performed one month after surgery highlighted a costal metastasis previously ignored.
RASND is a promising weapon to treat oligometastatic recurrent PCa. Up to one third of the patients reports biochemical response ant ADT is delayed. Oncologic outcomes reported in the few available series are affected by the limited sensitivity of Cho-PET/TC.