Robotic prostatectomy after abandoned open radical prostatectomy—Technical aspects and outcomes

Abstract Objective To describe the technical aspects and outcomes of robotic‐assisted radical prostatectomy (RARP) following abandoned open radical prostatectomy (ORP). Patients and Methods A retrospective review was performed of patients who underwent RARP following abandonment of ORP between 2016 and 2020. RARP was undertaken by two highly experienced robotic surgeons. Analysis of patient and operative characteristics, outcomes, and reasons for abandonment of ORP were described. Results Six patients were included for analysis with a median age of 63.5 years [50.3‐67.5]. The median body mass index (BMI) was 34.7 [27.8‐36.2]. All patients had intermediate‐risk prostate cancer. Small prostate and deep pelvis were given as reasons for abandoning ORP in five cases (83.3%), with four of these also attributing increased BMI as a factor. Extensive mesh from previous bilateral inguinal hernia repair was cited as the reason for abandonment in the remaining patient. One patient had commenced androgen deprivation therapy following abandoned ORP. Extensive retropubic adhesions were noted at the time of RARP in five of six patients, with intraoperative complication of small bladder lacerations encountered in the patient with prior mesh hernia repair. The median time from abandoned ORP to RARP was 128 days [40‐216]. Median operating time was 160 minutes [139‐190] and estimated blood loss was 225 mL [138‐375]. Negative margins were obtained in four of six cases, with further salvage treatment being required in one case at a median follow‐up duration of 10.5 months [6.5‐25.3]. Conclusion Abandonment of ORP is an uncommonly reported event, however, in this small case series, we demonstrate that, in the hands of experienced surgeons, RARP is a safe and technically feasible alternative in such cases. Increased BMI, small prostate size and pelvic anatomical constraints appear to be common catalysts for abandonment of open surgery in this cohort. Identifying these high‐risk patients early and considering referral to robotic centers may be preferred.


| INTRODUC TI ON
Although modern surgical technique for radical prostatectomy has been well described since the 1980s, it can still present numerous technical challenges to even the most experienced urologist regardless of the technique employed. 1 In general, these challenges largely relate to accessibility to the prostate gland within the pelvis which can be affected by several patient factors (Box 1). [2][3][4] Intraoperative abandonment of open retropubic radical prostatectomy (ORP) is an infrequent event with little published literature available.
Historically, treatment options following inability to complete surgical resection in this instance would include less invasive techniques such as external beam radiotherapy, brachytherapy, or watchful waiting. 5 However, with widespread adoption of robotic-assisted radical prostatectomy (RARP) over the past two decades, significant advances in surgical expertise in this field has improved ability to troubleshoot many of the patient factors that may preclude successful ORP. 6,7 Recently we have been referred a number of patients who have undergone attempted ORP with intraoperative abandonment for various anatomical and patient factors. We were successfully able to perform RARP as a salvage procedure. To the best of our knowledge, there is no preexisting literature examining such techniques. In this case series, we discuss the reasons for abandonment of ORP, technical challenges in approaching such cases, and outline short-term oncological and functional outcomes of these patients.

| PATIENTS AND ME THODS
In a multicenter retrospective review, six patients between 2016 and 2020 were identified to have undergone RARP following abandoned ORP. Two high-volume robotic surgeons (DGM and DM), who each perform greater than 100 RARPs per year, performed the procedures. Analysis of patient characteristics and their risk factors for difficult radical prostatectomy was undertaken, including reasons for abandonment of ORP. Operative video recordings of subsequent RARP were analyzed and areas of intraoperative difficulty assessed.
Postoperative outcomes including histology, hospital length of stay, and complication rate were recorded. Means and standard deviation (±SD) or medians and interquartile ranges [25-75] were calculated for continuous variables (depending on whether data were para-or nonparametric).

| Patient characteristics
Demographics, risk factors, and perioperative characteristics at time of primary attempted ORP are outlined in Table 1 Abbreviations: ADT, androgen deprivation therapy; BMI, body mass index; EBRT, external beam radiotherapy; ISUP, international society of Uro-pathology; ORP, open radical prostatectomy; PSA, prostatespecific antigen; RARP: robot-assisted radical prostatectomy.

| Abandonment of open prostatectomy
In all cases, initial attempted ORP was performed at external hospitals by experienced open surgeons. Reasons for abandonment were as described in operative reports and referral, including combination of elevated BMI, pelvic anatomical constraints and small, impalpable prostate in five cases. Loss of tissue planes due to extensive mesh inguinal hernia repair in a man with an otherwise normal stature and BMI was the cited cause for abandonment in the remaining patient.
Median time between abandoned ORP and RARP was 128 days . Only one patient received adjuvant treatment during this intervening time (androgen deprivation therapy (ADT)), however, two patients were initially referred for definitive external beam radiotherapy as an alternative treatment. This was commenced in one patient with initiation of ADT and implantation of fiducial seeds, however, the patient had a history of ulcerative colitis and developed rectal bleeding so radiotherapy was abandoned after only one fraction. Radiotherapy was declined by the second patient, aged 48 years, who sought robotic surgical opinion at our institution instead.

| Surgical approach and anatomical challenges
We describe our surgical technique and experience in these cases in the accompanying video. Following routine patient positioning and preparation, open Hassan entry was performed supra-umbilically avoiding the old lower midline scar ( Figure 1). In the case of the patient who underwent RARP only 1 day following abandoned ORP, the lower midline incision was left intact to maintain insufflation. Upon introduction of the camera, the abdomen was carefully inspected for adhesions that could affect port placement. Routine port placement was able to be performed in all cases and instruments introduced.
Commencing . In all cases, however, a good length of urethra was able to be preserved and the anastomosis was performed without any difficulty ( Figure 4).

| RE SULTS
Perioperative and postoperative outcomes are summarized in Table 2.
Each procedure was completed as described with a median operating  consequently resulting in proportional reduction in ORP being performed. 6 In Australia, access to RARP is readily available in the private sector, however, only few, more centralized, public hospitals have access to robotic equipment, including our own institution. 6 Accordingly,

| D ISCUSS I ON
ORP remains readily performed in the public healthcare system.
Although intraoperative abandonment of ORP is an uncommon occurrence, traditionally, subsequent treatment would be limited to radiation or non-curative management in the form of watchful waiting and hormonal therapy. 5 The shift in surgical proficiency in techniques for radical prostatectomy, however, has seemingly resulted in an inverse turn of events whereby abandonment of ORP may successfully be managed with conversion to RARP as demonstrated in our case series.  Abbreviations: IDC, in-dwelling catheter; ISUP, international society of Uro-pathology; PSA, prostate-specific antigen.
*Data missing for one patient due to insufficient follow-up time.