Ischemic Acute Liver Injury After Robot-Assisted Radical Prostatectomy

Summary

A 67-year-old man with prostate cancer developed acute liver injury after robot-assisted radical prostatectomy. The cause was an unknown narrowing of the celiac trunk, leading to reduced blood flow. He fully recovered with supportive care.

Abstract

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.

Introduction

The goal of this case report is to present ischemic acute liver injury (also known as ischemic hepatitis or shock liver) as an uncommon but serious perioperative complication following robot-assisted radical prostatectomy (RARP) in a patient with oligometastatic prostate cancer receiving neoadjuvant therapy, highlighting its diagnosis, conservative management, rapid recovery, and preserved oncologic outcome^1,2,3.

Oligometastatic prostate cancer is increasingly managed with multimodal approaches, including neoadjuvant androgen deprivation therapy (ADT) combined with novel hormonal agents such as apalutamide, followed by local therapy to improve progression-free survival^3,4. However, such regimens, combined with comorbidities, polypharmacy, and surgical factors (e.g., pneumoperitoneum, steep Trendelenburg positioning), may heighten risks of systemic complications, including hepatic hypoperfusion⁵.

Ischemic acute liver injury arises from an acute reduction in hepatic blood flow, typically without frank shock, leading to centrilobular necrosis, marked aminotransferase elevations (often >10x upper limit of normal, peaking within 1–3 days), and rapid resolution upon reperfusion if the insult is transient^6,7. It differs from drug-induced liver injury (prolonged exposure, cholestatic pattern) or viral hepatitis and is linked to low-flow states, vascular stenoses (e.g., celiac axis), or perioperative factors⁶. Reports of ischemic acute liver injury after urological procedures are sparse, with isolated cases tied to laparoscopic retraction or positioning, but none specifically describe post-RARP ischemic liver injury in the context of celiac trunk stenosis.

RARP offers advantages over open prostatectomy, including reduced blood loss, shorter hospitalization, and equivalent oncologic outcomes, but its prolonged pneumoperitoneum and extreme positioning can compromise splanchnic perfusion in predisposed patients (e.g., those with vascular stenoses or atherosclerosis)⁵.

The significance of this case lies in addressing an underreported scenario in the literature: perioperative ischemic hepatic injury in advanced prostate cancer patients on neoadjuvant therapy undergoing RARP, demonstrating early detection via routine labs and imaging, and successful multidisciplinary management.

Case Presentation
A 67-year-old male was diagnosed with prostate cancer in December 2021 (initial PSA 105 ng/mL, 11/12 biopsy cores positive, Gleason 3+4=7 with cribriform pattern, ISUP grade group 2). A thoracoabdominal computer tomography (CT) scan showed right inguinal lymph node metastasis and osteoblastic lesion in the right ilium. The right ilium bone lesion was also confirmed via skeletal scintigraphy. A pelvic magnetic resonance imaging (MRI) showed a locally advanced cancer extending beyond the prostate in the periprostatic tissue with suspected infiltration of both seminal vesicles (cT3b cN1 M1b). Comorbidities included hypertension, peripheral arterial disease, retinal detachment, and prior cataract surgery. Medications included acetylsalicylic acid, ramipril, amlodipine, simvastatin, and allopurinol. The patient had no significant residual urine and a prostate volume of 43 mL on transrectal ultrasound (TRUS), with intravesical prostate protrusion (IPP) grade I; International Prostate Symptom Score (IPSS) was 20 with a quality-of-life score of 3; International Index of Erectile Function (IIEF-5) score was 1/25.

Neoadjuvant ADT plus apalutamide 60 mg daily was administered for 6 months. Before initiating apalutamide and during therapy, liver function evaluation was normal, without any pathology. The CT scan 6 months after hormonal therapy began showed a reduction in lymph node size (from 1.5 cm to 0.5 cm) and a stable solitary bone metastasis. Prostate MRI showed a reduction in tumor size and prostate volume (23 mL). A very good biochemical response (preoperative PSA 0.6 ng/ml) was also achieved. Persistent severe lower urinary tract symptoms prompted the patient's preference for surgical management over radiotherapy. The preoperative laboratory workup, including transaminase levels, was within the normal range. Robot-assisted radical prostatectomy with extended pelvic lymphadenectomy was performed in August 2022, without intraoperative complications. Final pathology: ypT3b pN1 (15/19 positive nodes) M1b L1 Pn1 R0, minimal treatment effect (Helpap score 8)⁸. The console time was 120 min, the total surgical time was 135 min with minimal intraoperative blood loss (less than 100 mL).

On postoperative day 1, routine laboratory evaluation revealed elevated transaminases suggestive of diffuse liver injury. The patient was hemodynamically stable with no jaundice, encephalopathy, or abdominal pain. Abdominal ultrasound indicated features of acute hepatitis; contrast-enhanced CT showed reduced enhancement in the left hepatic lobe and severe celiac trunk stenosis.

Diagnosis, Assessment, and Plan
Initial evaluation included serial liver function tests and exclusion of congestive hepatopathy (no biliary dilatation or congestion on imaging). Differential diagnoses encompassed drug-induced liver injury from apalutamide or simvastatin and ischemic hepatitis. Infectious and autoimmune hepatitis were ruled out due to the absence of medical history or clinical signs.

The pattern of rapid aminotransferase rise, imaging evidence of celiac trunk stenosis with asymmetric left lobe hypoenhancement, and absence of alternative causes supported ischemic acute hepatic injury due to perioperative hypoperfusion (pneumoperitoneum, positioning, possible transient hypotension) on a background of preexisting vascular stenosis.

The plan included immediate ICU admission for close monitoring, intravenous fluid resuscitation to optimize perfusion, temporary discontinuation of potentially hepatotoxic medications (apalutamide held, simvastatin stopped), supportive care, and urgent multidisciplinary consultation with an academic liver center. No endovascular or surgical intervention for the stenosis was pursued after radiology and vascular surgery review, as the stenosis was non-occlusive and presumed to have adequate collaterals.

Protocol

The patient consented in writing to all treatment steps and anonymous publication. The study complies with the Declaration of Helsinki and was approved by the ethics committees of the Westfalen-Lippe Medical Association and the University of Muenster (2023–500-f-S) for retrospective data management.

1. Preoperative preparation

1. After the diagnosis was made, staging with a thoracic-abdominal CT scan, skeletal scintigraphy, and pelvic MRI was performed to evaluate the metastatic burden and the local extension of the disease. Lower urinary tract symptoms (LUTS) and sexual function were also assessed. The patient had severe LUTS (IPSS/Qol: 20/3) and severe erectile dysfunction (1/25).
2. After tumor board presentation, androgen deprivation therapy with an LHRH antagonist (3-month depot injection) was administered, combined with apalutamide (NHA) 60 mg orally daily for a duration of 6 months.
3. The CT scan and the pelvic MRI were repeated 6 months after therapy initiation and before the surgery to confirm tumor response to the hormonal therapy.
4. The lower urinary tract symptoms (LUTS) were reassessed. The LUTS did not improve significantly (IPSS score 17/3).

2. Patient positioning and robot docking

1. Following induction of general anesthesia, the patient was securely strapped to the operating table with arms at the sides and positioned in steep Trendelenburg (30° head-down). Adequate padding was applied at pressure points to prevent neuropraxia. The table was gradually tilted into the Trendelenburg position to facilitate pelvic exposure and was maintained in this position throughout the procedure.
2. Transperitoneal anterior approach: A supraumbilical mini-laparotomy was performed, and the capnoperitoneum was established through insufflation with CO2 (8 mm Hg).
3. Then the robotic trocars were inserted under direct vision: one 8-mm camera port at the umbilicus, two 8-mm robotic ports 8 cm away from the midline camera trocar bilaterally, and one 8-mm fourth trocar on the left abdominal side. Also, one 12-mm assistant trocar in the right lower abdomen quadrant and one additional 5-mm trocar in the right abdomen quadrant.
4. The robotic system was docked between the patient’s legs.
5. The robot instruments used were monopolar scissors, bipolar forceps, a grasping retractor, and a needle holder.

3. Robot-assisted radical prostatectomy with extended pelvic lymphadenectomy

1. After bipolar coagulation, the medial umbilical ligaments were dissected with the monopolar scissors, and the space of Retzius was entered. The bladder and prostate were then exposed anteriorly.
2. The endopelvic fascia was incised bilaterally with the monopolar scissors, and the prostate was released laterally from the levator ani muscles.
3. The bladder neck was identified and divided anteriorly with the robotic monopolar scissors, developing the plane until the Musculus vesicoprostaticus was reached.
4. Posterior dissection: the seminal vesicles and vasa deferentia were mobilized, the Denonvilliers' fascia was incised, and the posterior plane between the prostate and rectum toward the apex was developed using both the robotic monopolar scissors and the bipolar forceps.
5. Laterally: The plane between the prostate and the pararectal tissues was carefully dissected, and the neurovascular bundles had to be removed along with the prostate.
6. Apical dissection: the dorsal vascular complex (DVC) was transected using the robotic monopolar scissors, and the urethra was carefully dissected from the prostate to preserve its maximal intrabdominal length while not compromising the radicality of the surgery.
7. The DVC was ligated with 4-0 barbed suture.
8. Extended pelvic lymphadenectomy, including the internal, external, and common iliac vessels as well as the obturator fossa, was dissected using bipolar energy and clips to ligate the lymphatic vessels.
9. The vesicourethral anastomosis was carried out using a double-armed barbed suture.
10. An 18 Fr Foley catheter was inserted, and a leak test with 300 mL saline instillation was performed.

4. Postoperative management and monitoring

1. Upon identification of significant transaminase elevation on day 1, the patient was promptly transferred to the intensive care unit for close hemodynamic and organ function monitoring.
2. Intravenous fluid resuscitation was initiated using crystalloids.
3. The potentially hepatotoxic medications (apalutamide and simvastatin) were discontinued.
4. An abdominal ultrasound was performed.
5. Contrast-enhanced computed tomography (CT) was performed to evaluate for hepatic perfusion abnormalities and vascular anatomy.
6. Multidisciplinary consultation with hepatology, interventional radiology, and vascular surgery teams was obtained; no surgical interventions were suggested.
7. Supportive care (fluid optimization, avoidance of hepatotoxins, serial laboratory monitoring) was provided until liver function tests normalized.

Results

The procedure went without any complications. The console duration was 120 min; the whole operating time was 135 min, with minimal blood loss (<100 mL). Postoperatively and during routine controls on the first postoperative day, including abdominal sonography and laboratory workup, elevated transaminase levels were observed (Table 1). The case was therefore discussed with anesthesiologists, and the patient was transferred to the intensive care unit. Following consultation with the hepatology team, a h...

Discussion

Ischemic acute hepatic injury remains exceptionally rare following robot-assisted radical prostatectomy, with literature primarily describing retraction-related ischemia in laparoscopic urology or positioning effects, but no prior reports linking celiac trunk stenosis to this complication post-RARP ⁹. While spontaneous symptomatic celiac artery dissections are rare¹⁰, stenosis is more common¹¹. In this patient, preexisting undiagnosed celiac stenosis...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
12-mm assistant trocar	Applied medical	CFF73 Kii system	Right lower abdomen quadrant
5-mm assistant trocar	Applied medical	CFI05 Kii system	Right upper abdomen quadrant
8-mm robotic trocar	Intuitive Surgical	470179	Ports for robotic instruments
Apalutamide	Janssen-Cilag	59676-600-12	60 mg tablet, oral daily
Barbed suture (4-0)	Ethicon J&J	VLOCL	For dorsal vascular complex ligation
Bipolar forceps	Intuitive Surgical	471172	Robotic instrument
Double-armed barbed suture (3-0)	Ethicon J&J	VLOCM	For vesicourethral anastomosis
Grasping retractor	Intuitive Surgical	471344	Robotic instrument
Monopolar scissors	Intuitive Surgical	470184	Robotic instrument
Needle holder	Intuitive Surgical	420048	Robotic instrument
Robotic system	Intuitive Surgical	X system	da Vinci Surgical System
Endoscope / Camera	Intuitive Surgical	470027	30° da Vinci endoscope
Hem-o-lok clips	Teleflex	544230	Medium-large polymer clips for vascular control
Prolene suture (3-0)	Ethicon J&J	VCP333H	For bladder neck reconstruction
Laparoscopic suction irrigator	Applied Medical	C6001	For aspiration and irrigation
Foley catheter	Well Lead Medical	0165V18	18 Fr. 2 way
Surgical drapes	Microtek Medical	Ecolab RCD-100	Sterile procedure drapes