Robot-assisted radical cystectomy in a patient with muscle-invasive bladder cancer following radiotherapy for prostate cancer.

INTRODUCTION: Muscle-invasive bladder cancer following radiotherapy for prostate cancer is rare. We reported a case of muscle-invasive bladder cancer who underwent robot-assisted radical cystectomy following radiotherapy for prostate cancer. CASE
PRESENTATION: A 72-year-old man was referred to our division with a muscle-invasive bladder cancer. He had a history of intensity-modulated radiation therapy for localized prostate cancer. After three courses of platinum-based neoadjuvant chemotherapy, he obtained a radiologic complete response. He elected for robot-assisted radical cystectomy, standard lymph node dissection, and intracorporeal ileal conduit urinary diversion. Pathological findings revealed no residual tumor within the bladder and residual tumor in the prostate. He had discharged without any complications; and quality of life had improved.
CONCLUSION: A robot-assisted approach might be a potential option for well-selected patients with muscle-invasive bladder cancer who have previously received radiotherapy for localized prostate cancer.

gemcitabine plus carboplatin

intensity‐modulated radiation therapy

muscle‐invasive bladder cancer

neoadjuvant chemotherapy

prostate cancer

postoperative day

quality of life

robot‐assisted radical cystectomy

robotic‐assisted radical prostatectomy

radical cystectomy

radiotherapy

Although surgical treatment for patients with MIBC who have previously received RT for PC is challenging, this report indicates a robot‐assisted approach might be a potential option for well‐selected patients with MIBC who have previously received RT for localized PC.

Introduction

The incidence of MIBC following RT for PC is rare. RT for PC increases the risk for secondary bladder cancer with a risk ratio of 1.5.1, 2 With the increasing use of RT as a primary treatment for PC, the increasing risk of bladder cancer after RT for PC requires attention. Although RC remains the gold standard treatment for MIBC, a surgical treatment for these patients is challenging. RARC might be an option to reduce the surgical risk including complication. However, few cases of RARC have been reported in patients with PC after RT.3, 4 Herein, we reported a case of a patient with MIBC who underwent RARC following RT for PC.

Case presentation

A 72‐year‐old man received 76 Gy of IMRT for localized PC (initial prostate‐specific antigen level, 8.16 ng/mL; clinical stage, T1cN0M0; the Gleason score, 3 + 4; intermediate risk group). Two years after IMRT, he had macroscopic hematuria. Contrast‐enhanced computed tomography revealed the presence of MIBC cT3N0M0 (Fig. 1a). Transurethral resection of the bladder tumor revealed a high‐grade urothelial carcinoma. Subsequently, he received carboplatin‐based NAC (GCb) because of the renal impairment. Three courses after neoadjuvant GCb, he obtained a complete response (Fig. 1b). He was elected for RARC with nerve‐sparing procedure, standard lymph node dissection, and ileal conduit urinary diversion. Mild fibrous adhesion was observed around periprostatic lesions (Fig. 1c). As no tight adhesion was observed between the prostate and rectum, the separation of denonvilliers fascia was not challenging. Intracorporeal ileal conduit urinary diversion was performed (Fig. 1d). The operative duration and blood loss were 448 min and 210 g, respectively. The operative duration and blood loss were 448 min and 210 g, respectively. Although postoperative hemoglobin concentration was temporarily decreased from 9.9 to 7.8 g/dL, it was improved without perioperative blood transfusion. Pathological findings revealed no residual tumor (pT0) (Fig. 1e) and no lymph node metastasis (pN0). The residual tumor (Gleason score 3 + 3, pT2a) was detected within the prostate (Fig. 1f). The patient resumed peroral intake at POD 3, removed drainage tube and stent at POD 8 and POD 16, respectively.

Figure 1

Treatment outcomes. (a) Contrast‐enhanced computed tomography shows a well‐enhanced tumor of the bladder, invading all layers of the bladder. (b) Complete radiological response following three courses of NAC. Intraoperative finding of RARC. (c) Mild fibrous adhesion around periprostatic lesions. (d) Ileal conduit urinary diversion with the Wallace ureteroeneteric anastomoses was performed as an intracorporeal urinary diversion. (e) Histopathological findings reveal no residual tumor in the urinary bladder, diagnosed as pT0. (f) Residual tumor (Gleason score 3 + 3, pT2a) detected within the prostate.

The patient was discharged without any complications at POD 30. We evaluated his QOL before and 6 months following RARC using the European Organization for Research Treatment of Cancer QLQ‐30 ver. 3.0. Global functional (Fig. 2a) and symptom QOL (Fig. 2b) scores had improved 6 months following RARC from those before MIBC treatment.

Figure 2

QOL outcomes. (a) Comparison results of the QOL score before and 6 months following RARC showed improvement in global, physical, cognitive, emotional, and social QOL. (b) In the symptom QOL, nausea, sleep, appetite loss, and constipation showed improvement, whereas fatigue, pain, dyspnea, and diarrhea did not. A comparative change between constipation and diarrhea might have been caused by intestinal resection accompanying urinary diversion.

Discussion

We reported a case of RARC in a patient irradiated for PC, which showed the feasibility and safety of RARC in such a challenging case. RT for PC has been associated with a consistent increase in other pelvic malignancies, and bladder cancer risk has been reported in several studies.1, 2, 5 As patients who previously received RT for PC are not eligible for bladder preservation strategies, treatment options for patients with MIBC who have previously received RT for PC are limited. In addition, RC would be challenging due to fibrotic changes in the pelvis induced by radiation. An increased risk of complications was reported following pelvic radiation in open cystectomy.6 However, a previous study that investigated the safety of RARC in patients with previous history of pelvic irradiation concluded that complication rates were not differ between the patients with and without pelvic radiation.3 In addition, recent study for salvage RARP after radiation therapy suggested low complications rates including rectal injuries (<2%).7, 8, 9 A robotic procedure can overcome the difficulty of separation between the prostate and rectum. Based on this report, we selected RARC as definitive therapy for MIBC. As RARC can provide a fine and detailed view of the surgical field,10, 11, 12 we performed precision operation including the nerve‐sparing procedure, exfoliation of fibrotic tissues around the prostate, bladder, and rectum. Therefore, RARC is one of the options in selected patients with a previous history of pelvic irradiation.

MIBC patients with a history of pelvic irradiation have been reported with more advanced disease than de novo MIBC.1, 4, 5 Cisplatin‐based NAC improves survival outcomes in patients with MIBC.12, 13, 14, 15, 16 However, the efficacy of NAC for irradiation‐related MIBC remains unclear. Although a cisplatin‐based regimen is suggested as NAC, this patient was ineligible for cisplatin due to renal impairment. We selected three courses of neoadjuvant GCb and this patient obtained the pathological complete response. Although inferior efficacy of a carboplatin‐based regimen has been suggested, our previous study showed a low toxicity GCb regimen facilitated in completion of NAC, prevention of the delay in RC, and resulted in a favorable oncological and QOL outcome.12, 14, 15, 16, 17, 18, 19, 20 Therefore, neoadjuvant GCb might be an alternative option for MIBC patients with renal implement. Further studies are necessary to identify the ideal regimens for NAC including oncological and QOL outcomes.

Radiation treatment modality is a key point for patient selection for a surgical approach. As IMRT made radiation field reduction on the peri‐prostate and reduction in fibrotic change and adhesion around the prostate tissue possible, we neither had any difficulty performing RARC nor observed any postoperative complications. Although not many case series of salvage RARP after brachytherapy or proton therapy were reported, several studies suggested feasible outcomes in complications and functional outcomes.7, 8, 9 Moreover, the patient achieved QOL improvement 6 months following RARC in the global, physical, cognitive, emotional, social nausea, sleep, appetite loss, and constipation. Negative influence on diarrhea might be related to ileal conduit urinary diversion.

Conclusion

This case highlights a potential benefit of RARC for well‐selected patients with MIBC who have previously received RT for localized PC. The benefit of RARC in those patients needs further investigations.

Ethical statement

This study was approved by the institutional ethics committee of Hirosaki University School of Medicine (No. 2018‐062).

Conflict of interest

The authors declare no conflict of interest.