Background

Patients with nodal recurrence after primary treatment of prostate cancer benefit from nodal directed therapy. Salvage elective nodal irradiation is often the procedure of choice, while salvage lymph node dissection, particularly after prostate radiotherapy, is not usually considered because it is a very challenging procedure. Robotic-assisted lymph node dissection may change the scenario and provide surgery with better outcomes. We present a case of a robotic salvage lymph node dissection after primary treatment with prostate radiotherapy.

Case Presentation

Male patient, 62 years old, was diagnosed with prostate cancer Gleason 4+3 with initial PSA of 8 ng/mL. The CT scan and bone scintigraphy were negative. The patient underwent external beam radiotherapy (EBRT) plus 6 months of ADT in 2020. The PSA nadir was 0.18 ng/mL. He presented to our clinic 3 years later with biochemical recurrence (PSA was 3.21 ng/mL). The PET PSMA showed 1 positive external iliac lymph node at the right side with 2 cm. We repeated a transperitoneal prostate biopsy, which was negative.

The patient was proposed for a transperitoneal robotic-assisted laparoscopic salvage lymph node dissection. We have placed a 12 mm port above the umbilicus and 2 ports bilateral in the direction of the iliac crests. We performed bilateral lymph node dissection without any intraoperative or post-operative complications. Total procedure time was 1h22min. Estimated blood loss was 50 mL. Patient was discharged in 2 days. Histology revealed 18 lymph nodes, 2 positive lymph nodes at the right side. The Post-operative was PSA 0.021 ng/mL. 

Conclusion

Robotic salvage lymph node dissection after prostate radiotherapy is feasible and safe. For selected cases it may provide a valuable option after nodal recurrence.