Outcomes of Salvage Robot-assisted Radical Prostatectomy After Focal Ablation for Prostate Cancer in Comparison to Primary Robot-assisted Radical Prostatectomy: A Matched Analysis

Outcomes of Salvage Robotic-assisted Radical Prostatectomy: High-volume Multicentric Data from the European Association of Urology Robotic Urology Section Scientific Working Group

BACKGROUND AND OBJECTIVE

Salvage robotic-assisted radical prostatectomy (S-RARP) is one option for treating patients with recurrent prostate cancer after prostate-preserving primary therapy. However, the tissue damage, anatomical distortion, and lack of surgical landmarks caused by the primary treatment still constitute a major challenge to surgeons. We aim to report the experience of our group on S-RARP.

METHODS AND SURGICAL PROCEDURE

A retrospective multicentric study including data from nine centers from the European Association of Urology Robotic Urology Section Scientific Working Group was conducted. Overall, 397 patients who underwent S-RARP from 2008 to 2023 were included and divided into three groups (primary radiation therapy [RT], whole gland [WG] ablation, and focal gland [FG] ablation). The primary endpoints were the safety and feasibility of S-RARP. The secondary endpoints were the comparison of functional and oncological outcomes among different primary therapies.

KEY FINDINGS AND LIMITATIONS

The median (interquartile range) follow-up periods for RT, FG ablation, and WG ablation were 38 (19-73), 20 (10-37), and 24 (16-38) mo, respectively (p < 0.001). Only four patients (1%) had intraoperative complications and <2% had Clavien grade ≥3 after surgery. The 5-yr cumulative incidence rates of biochemical recurrence were 35%, 45%, and 23% for RT, FG ablation, and WG ablation, respectively (p = 0.3). The 3-yr cumulative incidence rates of continence were 67%, 92%, and 71% for RT, FG ablation, and WG ablation, respectively (p < 0.001). The 5-yr cumulative incidence rates of potency were 16%, 11%, and 5.3% (p = 0.2), while the overall survival rates at 5 yr were 95%, 94%, and 100% for RT, FG ablation, and WG ablation, respectively (p = 0.7).

CONCLUSIONS

S-RARP is safe and feasible with very low rates of perioperative complications. Functional outcomes in patients undergoing S-RARP are inferior to outcomes at primary surgery and demand highly skilled surgical expertise. Patients should be counseled carefully that the functional outcomes are inferior to those at primary surgery.

Surgical and oncological outcomes of salvage radical prostatectomy after focal therapies: a matched-pair analysis

OBJECTIVES

To determine the surgical and oncologic outcomes of salvage radical prostatectomy (sRP) after FT failure.

MATERIALS AND METHODS

Patients who consecutively underwent primary RP or sRP after FT failure between 2008 and 2022 were retrospectively selected. Primary or sRP were performed with either a robot-assisted or open approach. All surgeries were performed by surgeons with experience of ≥ 500 cases. Biochemical recurrence-free survival (BFS), intra- and postoperative surgical and functional outcomes were assessed. To evaluate the impact of surgical setting, propensity score (PS) matching was performed.

RESULTS

80 patients received sRP. Outcomes were analyzed using PS-matched cohorts (203 RPs vs. 68 sRPs). After a median follow-up of 25.4 months, sRP and RP had equal BFS (24mo-BFS: 72.4% vs. 76.0% (p = 0.8)). No statistically significant differences were found between sRP and RP in terms of median operative time (OT) (171 min vs. 168 min), estimated blood loss (EBL) (500 ml vs. 500 ml), length of hospital stay (LOS) (7 days vs. 7 days) and time to catheter removal (11 days vs. 11 days) and 1-year continence rates (all standardized mean differences ≤ 0.1). The main limitation is the retrospective study design.

CONCLUSION

In the hands of experienced surgeons, sRP after FT offered comparable surgical and oncologic outcomes as RP in a primary setting.

Salvage treatments after focal therapy for prostate cancer - a comprehensive review

OBJECTIVE

To review the literature on salvage treatments after focal therapy (FT) for prostate cancer (PCa).

MATERIALS AND METHODS

A non-systematic literature review was conducted on PubMed, Scopus, and Web of Science up to March 15, 2024, for studies that assessed salvage treatment outcomes in patients with recurrent PCa after primary FT. Original prospective and retrospective studies with more than 10 patients were included. Reviews, editorial comments, conference abstracts, and studies focusing solely on whole-gland treatments were excluded.

RESULTS

Twenty-one studies with a total of 1012 patients were included. The most reported salvage treatments were salvage radical prostatectomy followed by re-do ablation therapy. Only one study evaluated salvage radiation therapy. Except for one prospective study, all studies were retrospective. Oncological outcomes showed acceptable biochemical recurrence rates. Functional outcomes varied, with significant impacts observed on erectile function across modalities, though continence rates were less impacted. Complications were generally low across all treatment options.

CONCLUSION

Salvage treatment post-primary FT is feasible, safe, and has reasonable oncologic outcomes. However, significant declines in sexual function are common, while continence is comparatively less affected. The literature primarily consists of retrospective studies; hence, future research should focus on large-scale prospective evaluations to better define treatment protocols and improve patient outcomes.

Outcomes of salvage robot-assisted radical prostatectomy in patients who had primary focal versus whole-gland ablation: a multicentric study

In the present study, we present comparative outcomes of radical prostatectomy after whole-gland therapy (wg-SRARP) and focal gland therapy (f-SRARP). The study assessed 339 patients who underwent salvage robot-assisted radical prostatectomy (SRARP); 145 patients who had primary focal therapy and 194 patients who had primary whole-gland treatment. SRARP was performed in all cases using a standardized technique developed at respective institutes with the da Vinci Xi Surgical System. Our primary endpoint was the comparison of the functional and oncological outcomes between the groups. Cox proportional hazard was used to study the functional and oncological outcomes. The median total operative time for f-SRARP was 18 min higher than wg-RARP (p < 0.001). Higher rates of nerve-sparing were performed in f-SRARP (focal vs whole gland; bilateral-15.2% vs 9.3%; unilateral 49% vs 28.4%; p < 0.001). wg-SRARP had higher rates of ISUP 5 (26.3% vs 19.3%; p < 0.001) and deferred ISUP score due to altered pathology (14.8% vs 0.7; p < 0.001), while f-SRARP had higher rates of ISUP 4 (11.7% vs 10.7%; p < 0.001) and ≥ pT3a (64.8% vs 51.6%; p < 0.001). Positive margins were significantly higher with f-SRARP (26.2% vs 10.3%; p < 0.001). Functional outcomes were poor in both the groups. However, postoperative continence was higher and faster in patients who had f-SRARP compared to wg-SRARP (69% vs. 54.6%; p = 0.013). We could not identify statistically significant difference in postoperative potency recovery and biochemical recurrence. We present the largest multi-institutional analyses of f-SRARP and wg-SRARP. SRARP is challenging wherein patients have adverse pathological features and increased surgical complexity irrespective of the primary treatment. Focal therapy group had higher rates of nerve-sparing, however, with increased positive surgical margins. Both groups had poor functional outcomes regardless of nerve-sparing degree, indicating significant ipsilateral and contralateral damage to tissues surrounding the prostate during primary treatment. We believe that this analysis is crucial for counseling patients regarding expected outcomes before performing a salvage treatment following ablative therapy failure.

Outcomes of Salvage Robotic-assisted Radical Prostatectomy in the last decade: systematic review and perspectives of referral centers

PURPOSE

Salvage robotic-assisted radical prostatectomy (S-RARP) has gained prominence in recent years for treating patients with cancer recurrence following non-surgical treatments of Prostate Cancer. We conducted a systematic literature review to evaluate the role and outcomes of S-RARP over the past decade.

MATERIAL AND METHODS

A systematic review was conducted, encompassing articles published between January 1st, 2013, and June 1st, 2023, on S-RARP outcomes. Articles were screened according to PRISMA guidelines, resulting in 33 selected studies. Data were extracted, including patient demographics, operative times, complications, functional outcomes, and oncological outcomes.

RESULTS

Among 1,630 patients from 33 studies, radiotherapy was the most common primary treatment (42%). Operative times ranged from 110 to 303 minutes, with estimated blood loss between 50 to 745 mL. Intraoperative complications occurred in 0 to 9% of cases, while postoperative complications ranged from 0 to 90% (Clavien 1-5). Continence rates varied (from 0 to 100%), and potency rates ranged from 0 to 66.7%. Positive surgical margins were reported up to 65.6%, and biochemical recurrence ranged from 0 to 57%.

CONCLUSION

Salvage robotic-assisted radical prostatectomy in patients with cancer recurrence after previous prostate cancer treatment is safe and feasible. The literature is based on retrospective studies with inherent limitations describing low rates of intraoperative complications and small blood loss. However, potency and continence rates are largely reduced compared to the primary RARP series, despite the type of the primary treatment. Better-designed studies to assess the long-term outcomes and individually specify each primary therapy impact on the salvage treatment are still needed. Future articles should be more specific and provide more details regarding the previous therapies and S-RARP surgical techniques.

Rectal Perforation During Pelvic Surgery

Rectal perforations during pelvic surgery are rare but serious complications. The occurrence of rectal involvement is generally lower than that of the involvement of other portions of the bowel. The urologic field is responsible for the majority of iatrogenic rectal injuries from pelvic surgery; general and gynecologic surgeries are prone to the occurrence as well, the latter especially in the case of rectal shaving for deep infiltrating endometriosis. Attention should be posed to the prevention of rectal injuries, especially in case of challenging or salvage procedures; some tricks may be recommended to avoid thermal and mechanical damages and to realize a safe dissection. Intraoperative detection of rectal injuries is of paramount importance; once confirmed, immediate management with the closure of the defect is recommended. In general, rectal injuries diagnosed after surgery are liable to significantly worse outcomes than those detected and managed intraoperatively.

Patient summary

Rectal perforation is a rare but possible complication of pelvic surgeries. The more challenging the procedure (ie, surgery for locally advanced tumors or after radiation therapy), the higher the risk of rectal lesion. Intraoperative management of the injury should be attempted, with direct repair of the defect with or without fecal diversion.

Salvage robot-assisted radical prostatectomy following focal ablation with irreversible electroporation: feasibility, oncological and functional outcomes

Background

To report the feasibility, oncological and functional outcomes of salvage robot-assisted radical prostatectomy (sRARP) for recurrent prostate cancer (PCa) after irreversible electroporation (IRE).

Methods

This was a retrospective analysis of patients who underwent sRARP by a single high-volume surgeon after IRE treatment in our institution. Surgical complications, oncological and functional outcomes were assessed.

Results

15 patients with at least 12 months follow up were identified out of the 234 men who underwent primary IRE between 2013 and 2019. The median [IQR] age was 68 (62–70) years. The median [IQR] time from focal IRE to sRARP was 42 (21–57) months. There were no rectal, bladder or ureteric injuries. The T-stage was pT2 in 9 (60%) patients and pT3a in 6 (40%) patients. Only one (7%) patient had a positive surgical margin. At a median [IQR] follow up of 22 (16–32) months no patient had a biochemical recurrence (PSA > 0.2). All 15 patients were continent (pad-free) by 6 months and 9 (60%) patients had erections sufficient for intercourse with or without PDE5 inhibitors. No predisposing factors were identified for predicting erectile dysfunction after sRARP.

Conclusions

In patients with recurrent or residual significant PCa after focal IRE ablation it is feasible to obtain good functional and oncological outcomes with sRARP. Our results demonstrate that good outcomes can be achieved with sRARP, when respecting close monitoring post-IRE, good patient selection and surgical experience. The limitations of this study are that it is a small series, with short follow up and a lack of standardised quality of life instruments.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-022-00978-w.