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Robotic Abdominoperineal Resection with en Bloc Prostatectomy

Rectal cancer with local invasion presents a particular operative challenge. The standard procedure for locally advanced rectal cancer is a total pelvic exenteration (TPE), which is a highly morbid procedure. For select patients, the literature has demonstrated that bladder-sparing techniques involving en bloc resection of the prostate are safe and oncologically acceptable.1 Additionally, case studies have demonstrated the success of combined approaches using laparoscopic techniques.2,3 However, little has been published concerning the combined robotic-assisted approach of an abdominoperineal resection (APR) and en bloc prostatectomy with vesicourethral anastomosis. Robotic assistance offers several advantages for pelvic surgery, including better visualization using 3D technology and wristed instruments. Furthermore, research has shown the advantages of robotic surgery for rectal cancer resections.4,5

Our video presents a case of T4N0M0 rectal cancer, 1 cm from the dentate line, in a 63 year old male with invasion anteriorly into the prostate. After completing chemotherapy and radiation, a combined approach with a colorectal surgeon and a urologist was done using the daVinci Xi robot (Intuitive Surgical Inc, Sunnyvale, CA). The important steps of the procedure are demonstrated in the attached video. Pathology revealed a 5 cm mucinous adenocarcinoma with treatment effect and negative margins. The patient did well post-operatively with no complications. He was discharged on post-operative day 5.

Robotic-assisted procedures offer the advantage of precision and visualization for pelvic operations. For locally invasive rectal cancer, robotic surgery allows the opportunity to create novel techniques for select patients in order to reduce the number of TPEs.

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1. Saito N, Suzuki T, Tanaka T, et al. Preliminary experience with bladder preservation for lower rectal cancers involving the lower urinary tract. Journal of surgical oncology. 2010;102(7):778-783. 2. Kamiyama H, Sakamoto K, China T, et al. Combined laparoscopic abdominoperineal resection and robotic-assisted prostatectomy for synchronous double cancer of the rectum and the prostate. Asian journal of endoscopic surgery. 2016;9(2):142-145. 3. Nonaka T, Fukuda A, Maekawa K, et al. The Feasibility and Efficacy of Laparoscopic Extended Total Mesorectal Excision for Locally Advanced Lower Rectal Cancer. In vivo (Athens, Greece). 2018;32(3):643-648. 4. Bedirli A, Salman B, Yuksel O. Robotic Versus Laparoscopic Resection for Mid and Low Rectal Cancers. JSLS : Journal of the Society of Laparoendoscopic Surgeons. 2016;20(1). 5. Liao G, Li YB, Zhao Z, Li X, Deng H, Li G. Robotic-assisted surgery versus open surgery in the treatment of rectal cancer: the current evidence. Scientific reports. 2016;6:26981.

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