Abstract
Introduction:
Precision prostatectomy is a subtotal surgical treatment for patients with low and intermediate risk prostate cancer that involves extirpation of 95% of the prostate, while preserving a small rim of tissue along with the ipsilateral seminal vesicle (SV) to maximize nerve preservation during surgery. 1 Almost all patients after this procedure are continent, while 90% of patients maintain potency after surgery as a result of the enhanced nerve sparing. Due to its subtotal nature, few patients may continue to have a detectable prostate specific antigen (PSA) after surgery. Such patients are required to undergo a biopsy of the remnant prostatic tissue to rule out the presence of residual cancer.
Materials and Methods:
Two patients who underwent precision prostatectomy at our institution had a detectable PSA after surgery. These patients had Gleason 4 + 3 and Gleason 3 + 4 cancer pre-operatively, with pre-operative PSA values of 7.14 and 3.1, respectively. At 12 months, these patients had stable PSA values of 1.1 and 0.3 respectively and thus required a biopsy of the remnant. We used the ExactVu micro-ultrasound (mUS) system (Exact Imaging) to perform the biopsy, as it allows for greater visualization of the local tissue architecture in real time when compared with conventional ultrasound (US) approaches. 2 The US probe is inserted transrectally, and the bladder is identified as a relative landmark for the surrounding anatomy. The US probe is swept from right to left to bring the SV and prostatic remnant into view. The SV is identified by its characteristic hypoechoic appearance while the prostatic remnant is distinguished by its sharp demarcation from the surrounding tissue and is located adjacent to the SV. Once clearly identified, the biopsy needle is introduced transperineally to sample the prostatic remnant. Four to six cores are obtained during this procedure to ensure adequate sampling of the remnant.
Results:
The two patients had a total of 5 and 4 samples taken from the prostatic remnant, effectively sampling 1.25 cores/g of tissue and 2 cores/g of tissue, respectively. Both biopsies revealed benign prostatic tissue with no evidence of cancer in the remnant.
Conclusions:
Precision prostatectomy is a subtotal surgical treatment for prostate cancer with adequate cancer control that provides superior functional outcomes. Transperineal mUS-guided biopsy of the prostatic remnant can be performed in patients who have a detectable PSA after surgery in order to rule out the presence of residual cancer.
Patient Consent Statement:
Patient consent was obtained prior to the video submission for the purpose of scientific publication. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure.
Author Disclosure Statement:
Dr. Ash Tewari has served as a site-PI on pharma/industry sponsored clinical trials from Kite Pharma Inc., Lumicell Inc., Dendron Pharmaceuticals LLC, Oncovir Inc., Blue Earth Diagnostics Ltd., RhoVac ApS., Bayer HealthCare Pharmaceuticals Inc., Janssen Research and Development LLC. Dr. Tewari has served as an unpaid consultant to Roivant Biosciences and advisor to Proxamo. He owns equity in Promaxo.
Funding Information:
No funding was received for this article.
Runtime of video: 3mins 58 secs.
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