V14-10 ROBOTIC PROSTATECTOMY IN A PATIENT WITH AN ILEOANAL POUCH

Abstract

INTRODUCTION AND OBJECTIVE: Treatment for localized prostate cancer in men with prior history of total colectomy and ileoanal pouch anastomosis is complicated. Radiation therapy is mostly avoided due to the relatively high risk of pouch injury. Although a few robotic cases have been reported in the literature, no tutorial video has been shown. Herein, we present a case demonstrating step-by-step instructions, endeavoring to achieve oncological control and preserve functional outcomes in these complex cases. METHODS: A 68-year-old male with an ileoanal pouch due to ulcerative colitis, presented with PSA 19.3 ng/ml, bilateral Gleason 3+4, cT3a prostate cancer. RALP was chosen as treatment. Owing to the previous surgical scar, a paramedian incision was made, and the Hasson technique was used for camera port entry. After pneumoperitoneum was achieved, laparoscopic adhesiolysis was undertaken to release the right colon to introduce the assistant port; the rest of ports were inserted in a standard 6-port RALP fashion. The right vas was first identified near the internal inguinal ring. Because the ileoanal pouch was stuck posteriorly to the bladder, dissection was done along the right vas to trace down to both vasa and seminal vesicles. No Denonvilliers' fascia was present. Cautery was avoided during posterior and lateral periprostatic dissection. Because of severe adhesions between the prostate and pouch, the anterior approach was used to enter the space of Retzius. The vesicoprostatic junction was divided anteriorly and bladder neck sparing was performed. Blunt and sharp dissection with minimal use of diathermy was commenced to remove the prostate, dissecting the prostate off the pouch. The vesicourethral anastomosis was completed, with anterior reconstruction, and without Rocco posterior reconstruction. The leak test was negative. No pouch injury was confirmed using intraoperative air testing. An omental flap was developed and interposed between the pouch and bladder, to prevent fistula formation. After securing hemostasis, the specimen was extracted and port wounds were closed in layers. RESULTS: The entire procedure was performed without complication. Estimated blood loss was 350ml; console time was 130 minutes. The patient recovered well and was discharged on postoperative day 2. The pathology report revealed bilateral Gleason 3+4 =7, pT3a, with focal positive margins. At 1-month follow-up, he was wearing 3 pads per day, with minimal leakage at night. CONCLUSIONS: RARP is a feasible treatment option for prostate cancer diagnosed in men with ileoanal pouches, especially in experienced hands working in high-volume centers.