Comparison of outcomes of salvage robot‐assisted laparoscopic prostatectomy for post‐primary radiation vs focal therapy

Abstract

Objectives To compare salvage robot‐assisted laparoscopic prostatectomy (RALP) outcomes in patients who underwent radiation and those who underwent focal ablation as primary therapies. Patients and Methods We evaluated 126 patients who underwent salvage RALPbetween 2008 and 2018. Of these, 94 (74.6%) received radiation and 32 focal ablation (25.4%) as primary therapy. These groups were compared with regard to clinical, oncological and functional outcomes. Kaplan–Meier curves and regression models were used to identify survival estimations and their predictors. Results Before surgery, more patients were potent in the focal ablation group compared to the radiation group (46.9% vs 22.6%; P = 0.013). Peri‐operative characteristics and complication rates were not significantly different between the two groups. Postoperative catheterization duration was shorter in the focal ablation group (mean 10 vs 16 days; P = 0.018). At final pathology, the focal ablation group had higher non‐organ‐confined disease (71% vs 50%; P = 0.042) and positive surgical margin (PSM) rates (43.8% vs 17%; P = 0.004) as compared to the radiation group; however, 5‐year biochemical recurrence (BCR)‐free survival rates were similar (59% vs 56%; P = 0.761). Postoperative 1‐year full (no pads/day) and social (0–1 pad/day) continence rates were significantly higher in the focal ablation as compared to the radiation group (77.3% vs 39.2%, P = 0.002, and 87.5% vs 51.3%, P = 0.002, respectively). Multivariate analyses showed primary focal ablation and nerve‐sparing to be predictors of postoperative continence. Erectile function was preserved in 13% and 27% of preoperatively potent patients in the radiation and focal ablation groups, respectively (P = 0.435). No predictors were identified for postoperative potency. Conclusions Radiation was associated with inferior functional outcomes after salvage RALP. Focal therapies were associated with higher non‐organ‐confined disease and PSMrates, with no significant difference in short‐term BCR‐free survival.

Salvage Radical Prostatectomy for Radio-Recurrent Prostate Cancer: An Updated Systematic Review of Oncologic, Histopathologic and Functional Outcomes and Predictors of Good Response

“…In the absence of RCTs, all 23 studies that reported oncologic outcomes and were included in the analyses were of retrospective design (19 single center [12,[17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] and four multi center [5,[35][36][37]). The studies were published between 1988 and 2020.…”

“…The overall median time to SRP was 51 months (IQR 41-69) and overall median total serum PSA at SRP was 6.04 ng/mL (IQR 4.5-9.4). Information on the surgical technique was provided in 12 studies [5,12,[18][19][20][21][22][23][24]31,32,35], compromising 1277 patients. SRP was performed in open approach in 79.9% of the patients, robotic in 19.0%, and laparoscopic in 1.1%.…”

“…The definition of BCR after SRP varied between the different publications, although a PSA rise > 0.2ng/mL was the most widely used definition. The five-year BCR-free survival was reported in 10 out of 23 studies and ranged from 34% to 83% [5,12,17,19,22,25,27,33,35,37]. The 10-year BCR-free survival was available in two studies with 31% [23] and 37% [5].…”

“…Overall, 13 studies (four robotic (216 patients overall) [12,20,21,24], nine open (370 patients overall) [19,23,26,28,[30][31][32][33][34]) could be identified reporting on oncologic and functional outcomes after SRP. The outcome measurements and definitions for EF after SRP varied between the different studies: (1) "Sexual Health Inventory for Men" Questionnaire [12,20], (2) IIEF-5-Score [19], (3) "erection sufficient for penetration without PDE-5 inhibitors" [21], (4) "ability to have sexual intercourse with or without the use of PDE-5 inhibitors in >50% of the attempts" [23], (5) "normal erections during intercourse with or without PDE-5 inhibitor" [26]. EF before SRP was already poor with a great variability (two studies did not report on EF-rate before SRP [20,26]) ranging from 25.5% to 40.9%.…”

“…A systematic review of the literature published in 2012 by Chade et al [11] reported on the steadily improving outcomes of SRP resulting from surgical expertise and improved patient selection. Thanks to novel surgical techniques such as the robot-assisted approach [12] and the earlier detection of locoregional recurrent disease with novel superior imaging modalities in the BCR setting (i.e., PSMA-PET) [13], outcomes of salvage local surgical interventions promise to further improve [14]. Most guidelines recommend performing SRP in case of BCR after primary RT (1) in centers with great experience, (2) after confirmatory biopsy of the local relapse, (3) without clinical evidence of metastatic disease [1,15].…”