Transrectal Ultrasound-Guided Robotic Excision of Perirectal Lymph Node Metastasis After Primary Radical Prostatectomy

Abstract

Clinical History: A 60-year-old man with prostate specific antigen (PSA) of 10.8 ng/mL underwent a biopsy that showed grade group (GG) 5 adenocarcinoma of the prostate. The MRI showed organ-confined disease although there was an indeterminate 1 cm node in the left anterolateral perirectal fat. During the robotic radical prostatectomy, bilateral extended node dissection was performed, but the perirectal lymph node was not identifiable. Final pathology report confirmed adenocarcinoma GG5, pT2pN0MxR0, 22 lymph nodes were examined. At 3 months follow-up, PSA was 7.5 ng/mL. Diagnosis: Axumin positron emission tomography and computed tomography showed a solitary hot spot at the location of the perirectal node. We discussed treatment options androgen deprivation therapy, radiotherapy, and surgery. The patient elected for perirectal lymph node dissection (LND). In office contrast-enhanced transrectal ultrasound (TRUS) was performed. This confirmed location and visibility for planned intraoperative TRUS-guided excision. Intervention: Robotic LND started between the rectovesical pouch and the anterolateral aspect of the distal rectum. The node was identified with intraoperative TRUS and then a 17F Chiba needle was placed transrectally through the node into the surgical field. Transfixing the node gave direct vision and guided the robotic LND off the rectal wall and surrounding fat. There were no intraoperative complications, operative time was 214 minutes, estimated blood loss minimum, and length of stay 1 day. Follow-Up: Pathology report confirmed two distinct lymph nodes with metastatic prostatic carcinoma with 14- and 3-mm tumor deposit, respectively. PSA has remained undetectable at last follow-up, 40 weeks after LND. Authors do not have any commercial associations during the past 3 years that might create a conflict of interest in connection with the video. Authors have received and archived patient consent for video recording and publication in advance of video recording of procedure. Runtime of video: 5 mins