Robot-Assisted Radical Prostatectomy in a Patient with Pre-existing Femoral Crossover Bypass Graft: Multidisciplinary...

Robot-assisted radical prostatectomy (RARP) has become the standard surgical treatment for localized clinically significant prostate cancer, yet in patients with pre-existing pelvic vascular grafts, such as the iliofemoral graft, there is a significant risk of iatrogenic injury during abdominal access and pelvic dissection. This report describes a 69-year-old male with D'Amico intermediate-risk prostate cancer and a right iliofemoral polytetrafluoroethylene (PTFE) crossover bypass graft implanted for peripheral arterial disease. Major comorbidities included obesity (BMI 32 kg/m²), ASA III status, prior myocardial infarction with coronary stents, insulin-dependent type 2 diabetes, atrial fibrillation on apixaban, and Peripheral arterial disease under continuous antiplatelet therapy with aspirin. Preoperative magnetic resonance angiography enabled three-dimensional reconstruction of the graft course; vascular surgeons marked the graft trajectory directly on the abdominal wall to guide safe trocar placement. Aspirin continued perioperatively. Transperitoneal anterior RARP was performed with extended pelvic lymph node dissection (28 nodes, pN0). The graft was visualized intraperitoneally and avoided; cold scissors were used for dissection to minimize thermal injury. Operative time was 150 min, with an estimated blood loss of 300 mL. Final pathology revealed pT3a pN0 R0 disease with 4.8 cm³ tumor volume. Immediate continence was achieved after catheter removal. Graft patency was verified by Doppler ultrasound on day 1 and before discharge. PSA was undetectable (< 0.01 ng/mL) at 8 weeks and thereafter. This case illustrates that meticulous multidisciplinary planning enables safe RARP in high-risk patients.