Combined radical prostatectomy and abdominoperineal resection for locally invasive rectal cancer

Abstract

Introduction: An infiltration of urological organs is found in 5-10% of patients with colorectal carcinoma. Total pelvic exenteration is the standard procedure for locally advanced rectal cancer. In selected patients with rectal cancer involving the prostate or seminal vesicles, the bladder can be preserved and en bloc radical prostatectomy with abdominoperineal rectal resection can be performed. We report two patients who treated with this combined approach.

Presentation of case: Two patients with symptoms of rectal bleeding and pelvic pain were investigated. Colonoscopy demonstrated a tumor in the lower rectum. Biopsies revealed adenocarcinoma. Both pelvic MRI and endorectal ultrasound showed tumors that invaded the prostate and the seminal vesicles directly but without invasion of the bladder. After neoadjuvant chemoradiation, combined radical prostatectomy and abdominoperineal amputation was performed. None has developed local recurrence, but one of them was operated on for a single lung metastasis. After a follow-up of 28 and 20 months, respectively, the patients are alive without evidence of local recurrence or distant disease.

Discussion: This procedure obviates the need for urinary diversion without compromising the local tumor control. Intraoperative and postoperative diagnostic difficulties, and clinical aspects in relation to postoperative anastomotic leak and survival of patients are discussed.

Conclusion: En bloc radical prostatectomy and proctosigmoidectomy is feasible in selected patients with rectal cancer and invasion limited to the prostate or seminal vesicles because it provides good local tumor control and significantly improves the patient's quality of life in comparison to total pelvic exenteration.

Keywords: Abdominoperineal resection; Locally advanced rectal cancer; Radical prostatectomy; Rectal cancer.

Fig. 1

Axial T2 pelvic MRI demonstrates (A) infiltration of the prostate and (B) right seminal vesicle invasion (patient A).

Fig. 2

(A) Surgical specimen showing en bloc resection of the prostate and the rectum. (B) Histopathology confirmed a rectal adenocarcinoma infiltrating the prostate (H&E stain, 20×). (C) Cancer cells invading the prostate (H&E stain, 100×) (patient A).

Fig. 3

Axial (A) and sagittal (B) T2 pelvic MRI revealing prostatic involvement by cancer of the rectum (Patient B).

Fig. 4

(A) Mucin pools are observed (area bounded by a dotted line) less than 1 mm from the prostatic capsule (dashed line) (H&E stain, 50×). (B) Immunostaining was positive for CK AE1/AE3 demonstrating the presence of the tumor cells within collections of mucin (20× magnification). (C) Positive staining for CK 20 confirmed that the tumor cells belong to a rectal adenocarcinoma (400× magnification) (Patient B).