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Case History: Robotic Salvage Radical Prostatectomy after Primary Radiation Therapy for Prostate Cancer

A now retired 73 year-old serial entrepreneur, Art Wells, was diagnosed in 2010 with advanced (Gleason 8) but localized prostate cancer. After talking with urologic surgeons and radiation oncologists at the University of Kansas Medical Center and the Mayo Clinic, and voraciously reading about prostate cancer for two months, he chose to be treated at the Mayo Clinic with primary radiation therapy preceded by androgen deprivation therapy.

After treatment, his Prostate Specific Antigen (PSA) fell to undetectable levels for four and one-half years. Now, having moved his residence, his disease was being followed by an urologist at another leading medical school. This urologist determined that there was nothing he could do for him, given his undetectable PSA, and told him to have his primary care physician be the watcher of his prostate health.

Art, who devotedly kept up with the medical journal prostate cancer literature, thought following this advice was a recipe for doom. In any case, it wasn’t the kind of expert vigilance he wanted. Art immediately launched a search of the urology faculty at nearby Northwestern Memorial Hospital. Soon, he identified Shilajit Kundu, M.D. as most likely the right urologist/surgeon to give expert vigilance to his prostate cancer.
Dr. Kundu had the exquisite surgical training, clinical and surgical experience, research interests, and publications that strongly suggested that he was the doctor that could provide the advice, expertise, and care that Art wanted. Soon, Art was seeing Dr. Kundu every six months. From the very first appointment, already knowing about Dr. Kundu’s background, when Dr. Kundu indicated that medical risk-reward trade-offs to the patient must be balanced but the impact of taking risks for a patient on the surgeon’s own success numbers was not relevant, Art knew he had found the right urologist for him.

The first PSA test he had with Dr. Kundu showed that Art’s PSA was no longer undetectable. Over the next almost two years they discussed when they should begin aggressive action and what to do if recurrent cancer was identified. They concluded that if Art’s PSA reached 0.20 ng/ml they would do a MRI and biopsy. If cancer was confirmed, there would be four options: active surveillance, hormone treatment, focal therapy aimed at destroying the cancer, and salvage radical prostatectomy, an uncommon surgical operation that most urologists decline to do because of its technical difficulty but, the gold standard for giving the hope of cure for recurrent prostate cancer after primary radiation therapy. Art’s PSA reached 0.20 in January 2017 and the testing began.

Testing showed that the cancer was in Art’s prostate, with some of the cancer being aggressive Gleason 8. Because the PSA had been slowly but consistently rising it seemed unlikely that the cancer had metastasized and this was confirmed by a bone scan. The MRI showed that the cancer had likely escaped the prostate at its apex but was, otherwise, contained in the prostate. Dr. Kundu counseled doing a robotic salvage radical prostatectomy. Following Dr. Kundu’s advice, Art met with a leading oncologist and hematologist at Northwestern Memorial Hospital, who concurred with Dr. Kundu’s recommendation, and with a leading urologist at another medical school who is a pioneer with focal laser treatment for prostate cancer, a less invasive treatment for recurrent prostate cancer after primary radiation therapy. As he is wont to do, Art immersed himself in the medical literature, and he and his partner, Hope, asked the experts the best questions they could. Soon, it seemed obvious to Art and Hope, that Dr. Kundu was offering what seemed to be a real possibility of a cure but, in any case, a likely significantly longer cancer-free life, albeit with the possibility of some unwanted side effects like urinary incontinence. To Art and Hope, given the biopsy proven very aggressive cancer, active surveillance seemed completely wrong, hormone treatment is well-known to be non-curative, and the focal therapy simply didn’t have the same gold standard record for cure that salvage radical prostatectomy offered.

The surgery was scheduled, and took place with, what seemed to Art and Hope, an extraordinary team. They found out later that the surgery was sufficiently rare and fascinating that there were doctor onlookers in the operating room just watching the procedure.

Going into the surgery, Dr. Kundu knew it critical to ensure that all cancer near and outside the prostate apex was excised. After removing the prostate, he excised more tissue near where the prostate apex had been and that tissue along with the prostate was sent out for a pathology examination. The 2010 radiation therapy had made this operation difficult and it took a long time, almost five hours. But at the end of the operation, it seemed to Dr. Kundu that it had gone well.

When the pathology results came back, they showed that some of the cancer was very aggressive Gleason 9, and that Dr. Kundu’s decision to excise more tissue from near the prostate apex had been crucial. The cancer had escaped the prostate at the apex but examination of the excess tissue removed showed that Dr. Kundu excised all the cancer.

One day short of five weeks after the surgery, Art and Hope met with Dr. Kundu to review how things were going, and to do a blood draw for a PSA test. They were all hopeful but the PSA results would be determinative as to whether the operation was the success they were hoping for. That night, after Art was asleep, his cell phone rang and, somehow, however groggily, he answered it. He heard, “Art, this is Shilajit Kundu. I know I’m waking you up but I thought you would want to know. Your PSA is zero point zero zero.”

That news really woke Art up. Dr. Kundu had achieved the gold standard! What a moment! And Dr. Kundu was just as happy! And a few minutes later when Art told her, so was Hope!