Challenging Case: Robot-Assisted Laparoscopic Prostatectomy After Prior Suprapubic Open Prostatectomy

Introduction: Given the ubiquity of robot-assisted laparoscopic prostatectomy (RALP) for treatment of localized prostate cancer, more surgeons are encountering challenging cases, either secondary to difficult anatomy, prior abdominal surgery, or prior radiation therapy. Our case is of RALP in a patient after prior suprapubic prostatectomy. Case Presentation: A 61-year-old otherwise healthy Hispanic gentleman presented for consultation after being found to have Gleason 4 + 4 = 8 prostate cancer on transrectal ultrasound-guided biopsy by an outside provider in July 2017. He had previously undergone suprapubic simple prostatectomy for benign prostatic hyperplasia (BPH) in Nicaragua more than a decade prior. The patient underwent RALP with bilateral nerve sparing in September 2017. The surgery was challenging in that extensive lysis of adhesions had to be performed and typical dissecting planes at the bladder neck and apex were distorted, insofar as meticulous care was taken to judiciously use thermal energy and rely on blunt dissection at these critical junctures. That being said, there were no operative or postoperative complications, the patient was discharged on postoperative day 1, and at 3-month follow-up, the patient was fully continent, maintained erections adequate for sexual intercourse, and had a prostate specific antigen <0.1. Pathology report returned Gleason 3 + 3 = 6 disease with negative surgical margins. Discussion: There is only one other example in the literature of RALP being performed after prior suprapubic prostatectomy. Our large RALP case volume (>5000 patients for a single surgeon and counting) provided us with the necessary experience required for encountering atypical anatomy, and thereby contributed to our patient's effective surgical outcome, both oncologic and functional. Conclusion: RALP for treatment of prostate cancer is a safe and appropriate option in men who have previously undergone suprapubic open prostatectomy for BPH, especially in the hands of an experienced surgeon.