A case report of intraoperative detection an appendicular mucosal neoplasm during robotic assisted radical prostatectomy—da Vinci

Introduction

Prostate cancer is the most commonly diagnosed cancer in men in Europe and the third leading cause of death (1). Currently, the most frequently chosen form of surgical treatment in the world is robot-assisted laparoscopic radical prostatectomy. Robots have found many applications in surgical treatment, not only in urology. They are used for gastrointestinal surgery, gynaecological, laryngological and even cardiac operations (2). The case describes the possibility and safety of using the da Vinci robotic system to perform simultaneous surgery to remove multiple cancerous lesions without prior preparation and need to change the access of the surgical field and the method. Appendix neoplasms are very rare, but sometimes they are detected accidentally (3). We present this article in accordance with the CARE reporting checklist (available at https://ls. amegroups.com/article/view/10.21037/ls-24-16/rc).

Case presentation

A 64-year-old man was admitted to the Department of Urology and Urological Oncology for radical prostatectomy. Patient with no history of previous illnesses or surgeries in the past. Ailments only related to benign prostatic hyperplasia, such as weakened urine stream, prolonged micturition time. Prostate cancer was detected during preventive visits to the urology clinic.

The examination: digital rectal examination (DRE) revealed a palpable tumor in the right lobe—cT2b. Prostatic specific antigen (PSA) level was 4.9 ng/mL. Magnetic resonance imaging (MRI) of the prostate gland was described as Prostate Imaging Reporting & Data System (PIRADS) 5—lesion in the right lobe. The lesion adheres to the pseudocapsule with its possible infiltration. In the prostate biopsy detected positive sections from the right lobe—Gleason was 4+3. Lobular adenocarcinoma was found and assessed as grade 3. In the remaining examinations there were no signs of proliferative disease. The only deviations were noted in MRI, which showed a layer of fluid up to 23 mm thick in the recto-vesical pouch and also in interloop space.

The patient was qualified for laparoscopic radical prostatectomy assisted by the da Vinci robot (4-6). During the procedure, after visualizing the peritoneal cavity, a large amount of greenish mucus was observed in the pelvis and within loops of intestine. Looking for the source of the mucus, the operative team found a distal appendix tumor (7-9). In the first stage of the procedure, a radical prostatectomy was performed, followed by an appendectomy. Obturator lymph nodes were also removed and specimens were taken from the papularly altered parietal peritoneum by the general surgeon. The specimens were submitted to histopathological examination.

Finally, globular adenocarcinoma with Gleason 3+4 and grade group 2 pT2c N0 Mx R1 was diagnosed in the prostate gland (Figures 1,2). Histopathologically, the tumor in the appendix was mucinous neoplasm with a higher histological grade [high-grade appendicular mucinous neoplasm (HAMN)] pTis R0 (Figures 3,4). The postoperative period was uncomplicated. Further oncological treatment of the patient from the urological side is monitoring of the PSA value and observation for possible biochemical recurrence. The patient’s level of PSA after 6 months after the surgery was under 0.006 ng/mL. The colonoscopy, conducted in September 2024, has shown lack of any changes in the surroundings of the appendix. For mucinous appendix cancer, the patient should receive adjuvant treatment with hyperthermic intraperitoneal chemotherapy (HIPEC) or systemic chemotherapy (9).

Figure 1 Histopathology—appendix wall, high grade dysplasia (staining method: hematoxylin and eosin; scale bar: 200 µm).

Figure 2 Histopathology—appendix wall, high grade dysplasia (staining method: hematoxylin and eosin; scale bar: 100 µm).

Figure 3 Histopathology—prostate cancer Gleason 4 component (staining method: hematoxylin and eosin; scale bar: 200 µm).

Figure 4 Histopathology—prostate cancer nerve perineural invasion (staining method: hematoxylin and eosin; scale bar: 100 µm).

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Conclusions

It may happen that during a planned radical prostatectomy surgery performed with the assistance of the da Vinci robot, a suspicious lesion is found in the peritoneal cavity. Appendectomy is a possible treatment for intraoperatively detected tumors in the appendix to protect against further complications (3). If appendicular myxoma is detected, it may be pseudomyxoma peritonei, which is a tumor located in the peritoneal cavity that can cause dyspeptic symptoms, abdominal pain, bloating or infertility. In the described case, however, the development of the disease was asymptomatic.

Particular attention is also drawn to the lack of specific changes in the imaging tests performed before the procedure—only the fluid in the pelvic MRI. In the presented case, after the removal of the prostate, seminal vesicles and part of the vas deferens by urologists, it was possible to perform an appendectomy by a general surgeon as part of a consultation during a single anesthesia, without changing the method or surgical access. Not only do many scientific papers indicate fewer complications of robot-assisted laparoscopic surgery than other forms of surgical treatment of prostate cancer (4-6), but also in the case of suspected other abdominal lesions, robotic assistance provides the possibility of an efficient resection.

There is also important to mention the surgical access used during the procedure. It was the transperitoneal approach. If a different approach was used, it would not be possible to visualize the peritoneal cavity and detect a change in the appendix. Earlier methods of surgical treatment of prostate cancer, and in some lower-level referral hospitals still used today, would not allow the peritoneal cavity to be visualized, because they are performed from a preperitoneal approach.

It is also worth emphasizing that due to the presence of mucus in the peritoneal cavity detected intraoperatively in the patient, adjuvant HIPEC treatment is recommended (7-9). After the radical prostatectomy for tumor, further observation and monitoring of PSA level for possible biochemical recurrence is recommended, which would be an indication for adjuvant treatment.

On the basis of the considerations and the cited literature, it can be concluded that in the case of a high probability of multiple neoplastic lesions within the abdominal cavity, the use of laparoscopy assisted by the da Vinci robot should be the preferred method of surgical treatment, as it creates the possibility of efficient resection of all lesions even if they are accidentally detected. Additionally, performing a surgery with two procedures can lower side effects of the medicines given during two individual surgeries. The patient had lower chance to develop nausea, vertigo, head pain or even complications with breathing after one surgery than the two ones.

Acknowledgments

We would like to acknowledge Prof. Ewa Iżycka-Świeszewska (MD, PhD), Hanna Majewska (MD, PhD) and Natalia Walkusz (MD) for preparing and sharing histopathological examination results.

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://ls.amegroups.com/article/view/10.21037/ls-24-16/rc

Peer Review File: Available at https://ls.amegroups.com/article/view/10.21037/ls-24-16/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ls.amegroups.com/article/view/10.21037/ls-24-16/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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