Practitioner's Words:
Here is a case study of radical prostatectomy after electroresection followed by endocrine therapy. The surgeon admitted a high-risk prostate cancer patient and underwent radical prostatectomy surgery after endocrine therapy for 11 months.
The question of whether neoadjuvant endocrine therapy should be given to patients with high-risk prostate cancer prior to radical prostatectomy is controversial. After endocrine therapy, the adhesion between the prostate and tissues is aggravated, the intraoperative anatomical difficulty is increased, and the data show that endocrine therapy does not benefit patients in the long term and increases the risk of drug-related adverse reactions. However, some studies have shown that preoperative endocrine therapy can reduce the clinical stage of surgery, reduce the early tumor burden, reduce the positive rate of surgical margins, and also enable some patients with local tumor progression to obtain the opportunity of radical surgical resection.
We welcome your views on what treatment options will best benefit your patients.
Case Profile
The patient, a 68-year-old male, was presented to a local hospital for ultrasound examination showing that the prostate malignant tumor invaded the bladder due to painful urination pain and discomfort 11 months ago, transurethral prostate bladder tumor resection, postoperative pathology showed prostate cancer, and endocrine therapy was given, oral bicalutamide tablets 50mg once a day, subcutaneous injection of goserelin acetate 10.8mg 1/3 months, a total of 11 months of internal treatment, After 3 months, the re-examination of prostate magnetic resonance showed that the tumor recurred, and he was hospitalized again for vaporization resection of transurethral prostate bladder tumor, and the pathological results showed prostate adenocarcinoma (Gleason score 4+4=8 points).
入院查T-PSA：4.08ng/ml。
CT abdomen
01 Surgical plan and key points of surgerySurgical plan: Radical prostatectomy is performed
Key points of surgery:
(1) Incision of the peritoneum extending to both sides to the level of the vas deferens at the bilateral inner rings is conducive to exposing the surgical area during surgery. (2) Conventional suturing DVC can reduce intraoperative bleeding, and some patients with sexual preservation function report strong penile erection hardness after surgery. (3) For the incision of the bladder neck and the judgment of the position of the bladder neck, our commonly used methods are:
- In the Maryland method, the second arm is used to observe the softness and firmness and freeness of the bladder neck tissue to judge the prostate-bladder junction;
- The assistant pulls the catheter method.
(4) After opening the bladder neck, the long straight needle passes through the lateral hole of the urethral catheter, penetrates the abdominal wall, and uses the urethral catheter to pull up the prostate, which can continue to maintain tension, and free up three arms to better assist in exposing the seminal vesicles, bilateral lateral ligaments, and Dihl's fascia of the rectum. (5) The seminal vesicle artery does not need to be deliberately clamped, and the electrocoagulation can be paid attention to. (6) Because the patient is at high risk of prostate cancer, the rectum must be protected between the free prostate and the rectum, even if the gland remains on the surface of the rectum, do not damage the rectum, because only if there are no surgical complications, the operation is beneficial, and other treatments can be carried out after surgery, such as radiotherapy, chemotherapy, etc. (7) Single-needle barb line continuously anastomoses the bladder, neck, and urethra. Starting at 3 o'clock and ending at 3 o'clock, if the bladder neck is large, bladder neck reconstruction can be performed.
Answer: For patients who have been on endocrine therapy for 11 months, how to deal with adhesions during surgery?
After endocrine therapy, the periprostate boundaries are unclear, but the prostate outline is still discernible.
During the operation, it was found that even if the patient's prostate cancer and rectal adhesions were serious, it was still necessary to pay attention to protecting the rectum, and it was recommended to protect the rectum from damage, preferring a positive margin, because this surgery for advanced prostate cancer, as long as there are no complications, the patient is beneficial (there are articles clearly reported abroad).
If the seminal vesicles are violated, the intraoperative adhesions are also more serious, often the seminal vesicles are in an atrophic state, and the texture is particularly hard, close to the prostate, pay attention to the magnetic resonance film before the operation to determine the shape and size of the seminal vesicles, so that the intraoperative resection is targeted.
Please scan the QR code below to watch the surgery video
Postoperative pathology: 1. Prostate tissue was sent for examination with inflammatory cell infiltration, fibrous tissue hyperplasia, necrosis and multinucleated giant cell reaction, combined with clinical changes after treatment, local detection of residual prostate adenocarcinoma, Gleason 4+4=8 points, local invasion of nerve tissue and surrounding adipose tissue; 2. A small amount of seminal vesicle gland tissue was found next to the prostate, and no cancerous tissue was found; 3. No cancerous tissue was found in the urethral stump.
Postoperative pathology
Operator's introduction
Fu Qiang
Tangdu Hospital affiliated to the Air Force Military Medical University
Deputy Chief Physician
Major Academic Appointments:
Deputy Director General of the Urology Branch of Shaanxi Medical Doctor Association
Member of the Standing Committee of Shaanxi Provincial Urological MDT Branch of Integrated Traditional Chinese and Western Medicine
Member of the Standing Committee of Shaanxi Provincial 3D Printing and Digital Medical Association
Member of the Abdominal Surgery Branch of Shaanxi Rehabilitation Medical Association
Member of the Urology Professional Committee of Shaanxi Rehabilitation Medical Association
Da Vinci Robotic Surgeon Surgeon Qualification. The "Robotic Radical Prostatectomy Surgery" in the Urology Surgery Video Contest won the Outstanding Surgery Award. He has participated in 4 projects of the National Natural Science Foundation of China, presided over one provincial key R&D project, won 4 national new invention patents, participated in the compilation of 2 books, and published more than 50 articles in SCI and domestic core journals.
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