Ischemic Acute Liver Injury After Robot-Assisted Radical Prostatectomy

Ischemic acute liver injury is a rare, potentially life-threatening complication after major urological surgery, particularly in patients with advanced prostate cancer on neoadjuvant systemic therapy. This report describes a 67-year-old male with oligometastatic prostate cancer (cT3b cN1 M1b, initial prostate-specific antigen (PSA) 105 ng/mL) who received 6 months of neoadjuvant androgen deprivation therapy (ADT) combined with apalutamide. Due to persistent severe lower urinary tract symptoms, patient preference, and a very good response to hormonal therapy (preoperative PSA 0.6 ng/mL), robot-assisted radical prostatectomy with extended pelvic lymphadenectomy was performed uneventfully. On postoperative day 1, routine blood tests revealed elevated transaminases consistent with ischemic acute liver injury. The patient remained hemodynamically stable without jaundice or encephalopathy. Abdominal imaging demonstrated reduced contrast enhancement in the left hepatic lobe due to severe celiac trunk stenosis. Infectious, autoimmune, and primary drug-induced causes were not clinically suspected. Ischemic acute hepatic injury secondary to perioperative hypoperfusion superimposed on preexisting celiac trunk stenosis was diagnosed. Management involved intensive care monitoring, intravenous fluid resuscitation, temporary discontinuation of potentially hepatotoxic medications, and multidisciplinary consultation with a specialized liver center. No revascularization or other invasive interventions were required. Liver function improved partially by day 7 and normalized at long-term follow-up. At the 4-year follow-up, PSA remained undetectable (0.03 ng/mL) under ongoing dual hormonal therapy, with no evidence of biochemical or radiographic recurrence. This case illustrates the importance of perioperative liver monitoring in at-risk patients, the transient nature of mild ischemic acute liver injury with prompt supportive care, and the viability of multimodal treatment, including surgery for selected oligometastatic prostate cancer cases.