Linfadenectomia rob?tica retroperitoneal e p?lvica de salvamento no c?ncer de pr?stata com recidiva linfonodal : t?cnica e s?rie inicial

Introdu??o: Apesar do tratamento inicial do c?ncer de pr?stata na doen?a clinicamente localizada com cirurgia ou radioterapia externa, entre 20 a 40% dos pacientes ir?o apresentar recidiva em 5 ano e entre 25 a 35% dos pacientes progredir?o para doen?a metast?tica. Linfadenectomia de salvamento tem sido proposta em pacientes com recidiva bioqu?mica do c?ncer de pr?stata e acometimento linfonodal apenas, embora o nivel de dissec??o permane?a em debate. Neste trabalho descrevemos a t?cnica de linfadenectomia estendida retroperitoneal e p?lvica rob?tica de salvamento para c?ncer de pr?stata recorrente e reportamos a s?rie inicial Materiais e M?todos: Um total de 23 pacientes com recidiva bioqu?mica e doen?a linfonodal pelo PET/CT foram submetidos prospectivamente a linfadenectomia rob?tica estendida retroperitoneal e p?lvica de salvamento no per?odo de setembro de 2015 a dezembro de 2016 no Keck Hospital da University of Southern California (USC), Los Angeles, CA, EUA. O n?vel de ressec??o estende-se cranialmente da veia renal esquerda e art?ria renal direita at? o linfonodo de Cloquet caudalmente, excisando completamente o tecido linf?tico-adiposo ao longo da aorta, cava e vasos il?acos. Resultados: Idade mediana na linfadenectomia foi 64 anos (46-77 anos), IMC mediano foi de 26.2 kg/m2 (21.7 ? 33,8 kg/m2), tratamento prim?rio pr?vio foi prostatectomia radical em 20 pacientes (86%) e radioterapia externa em 3 pacientes (14%), tempo do tratamento prim?rio at? a linfadenectomia foi de 42 meses (1-163 meses) e PSA foi de 3,18 ng/ml (0.28 ? 32,6 ng/ml). Tempo operat?rio mediano foi de 305 minutos (209-433 minutos), sangramento foi de 100 ml (25-400 ml) e tempo de hospitaliza??o de 1 dia (1-6 dias). N?o houve complica??o intra-operat?ria, convers?o para cirurgia aberta ou transfus?o sangu?nea. Cinco pacientes apresentaram complica??es Clavien-Dindo Grau I no p?s operat?rio: ?leo em 2 pacientes (8,7%), parestesia na coxa em 1 paciente (4,3%) e linforr?ia em 2 pacientes (8,7%). Tr?s pacientes desenvolveram complica??es Clavien-Dindo Grau II: equimose do flanco e bolsa escrotal em 1 paciente (4,3%), ascite quilosa em 1 paciente (4,3%) e neuropraxia em 1 paciente (4,3%); e 1 paciente (4,3%) necessitou drenagem de linfocele (IIIa). A an?lise histol?gica confirmou met?stase linfonodal em 19 pacientes (83%). O n?mero de linfonodos m?dios e medianos (intervalo) por paciente foram 84 e 89 (27-132 linfonodos) respectivamente. O n?mero de linfonodos m?dios e medianos (intervalo) por paciente foram 24 e 6 (0-109 linfonodos) respectivamente. Aos dois meses de p?s operat?rio, o PSA mediano foi de 0,41 ng/ml (0.01 ? 8,3 ng/ml); houve redu??o m?dia de 79% (intervalo de 0 a 97,5%). Em 4 pacientes o primeiro PSA no p?s operat?rio foi menor de 0,2 ng/ml. Conclus?es: A linfadenectomia estendida retroperitoneal e p?lvica rob?tica de salvamento replica a cirurgia aberta, com maior n?mero de linfonodos e morbidade diminu?da comparada com a literatura. Neste trabalho descrevemos a t?cnica e reportamos a s?rie inicial. Maior acompanhamento a longo prazo ? necess?rio para a avalia??o dos desfechos oncol?gicos. Introduction: Despite primary treatment of prostate cancer with surgery or external radiation therapy, 20-40% of patients relapse within 5 years and 25-35% progress to metastatic disease. Salvage lymph node dissection has been proposed in patients with biochemical recurrence from prostate cancer and nodal involvement only, although the optimal template remains a question of debate. Herein we describe the technique of robotic extended salvage retroperitoneal and pelvic lymphadenectomy (sRPLND+PLND) for "node-only" recurrent prostate cancer and report the initial series. Materials and Methods: Twenty three patients underwent robotic sRPLND+PLND for "node-only" recurrent prostate cancer after definitive primary treatment as identified by PET/CT from September 2015 to December 2016 at Keck Hospital of University of Southern California (USC), Los Angeles, CA, USA. Our anatomic template extends from left renal vein and right renal artery cranially up to Cloquets node caudally, completely excising lymphatic-fatty tissue from aorto-caval and iliac vascular trees. Meticulous node-mapping assessed nodes at 4 prospectively-assigned anatomic zones. Results: Median age at salvage RPLND was 64 years (46-77 years), median BMI was 26.2 kg/m2 (21.7 ? 33,8 kg/m2), previous primary treatment was radical prostatectomy in 20 patients (86%) and external radiation therapy in 3 patients (14%), median time from primary treatment was 42 months (1-163 months) and median PSA at sRPLND+PLND was 3.18 ng/mL (0.28 ? 32.6 ng/mL). Median operative time was 305 minutes (209-433 minutes), blood loss was 100 ml (25-400 ml), and hospital stay was 1 day (1-6 days). No patient had intra-operative complication, open conversion or blood transfusion. Five patients had Clavien-Dindo Grade I post-operative complications: ileus in 2 patients (8,7%), thigh paresthesia in 1 patient (4,3%) and lymphorrhea in 2 patients (8,7%). Three patients had Clavien-Dindo Grade II complications: flank/scrotal ecchymosis in 1 patient (4,3%), chylous ascites in 1 patients (4,3%) and neuropraxia in 1 patient (4,3%); and 1 patient (4,3%) had lymphocele requiring drainage (IIIa). Final histology confirmed positive nodes in 19 patients (83%). Mean and median (range) number of nodes excised per patient was 84 and 89 (27-132 nodes) respectively. Mean and median (range) number of positive nodes was 24 and 6 (0-109 nodes) respectively. At 2 months post-operatively median (range) PSA was 0.41 ng/mL (0.01-8,3 ng/mL); median decrease of 79% (0-97,5%). In 4 patients the first PSA levels were less than 0,2ng/ml. Conclusion: Herein we describe the detailed technique of robotic high-extended salvage RPLND+PLND for "node-only" recurrent prostate cancer and present the initial experience. Robotic sRPLND+PLND duplicates open surgery, with superior nodal counts and decreased morbidity compared to the published literature. Longer follow-up is necessary to assess oncologic outcomes. Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior - CAPES