Robot-Assisted Radical Prostatectomy in a Post-Enucleation Gland.
Paulo Roberto Salustiano de Carvalho, Rafael Gomes Viterbo, Fabrício Borges Carrerette et al.
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Case in brief
A 64-year-old man was found to have right-lobe ISUP grade 3 prostate adenocarcinoma after HoLEP for benign prostatic obstruction. PSA was 0.51 ng/mL, and MRI showed a 0.4 cm PI-RADS 4 lesion. He underwent robot-assisted radical prostatectomy 29 months after HoLEP. Pathology showed bilateral Gleason 7 (4+3), pT2c adenocarcinoma with negative margins. He was discharged the next day; the catheter was removed on day 5. At six weeks, he was continent without pads and had an undetectable PSA.
What made this case unusual
Post-enucleation fibrosis and loss of adenoma altered the operative anatomy: the capsule was flaccid, and landmarks for the bladder neck and neurovascular bundle were less distinct. The report demonstrates practical responses, including using the balloon or extravesical landmarks as a reference and rotating the 30-degree lens to open the posterior plane.
Diagnostic / clinical pearl
After HoLEP, fibrosis and altered tissue support can obscure landmarks during prostatectomy; particular caution is warranted at the bladder neck and posterior plane.