Extended robot‐assisted laparoscopic prostatectomy and extended pelvic lymph node dissection as a monotherapy in patients with very high‐risk prostate cancer Patients

Abstract

Background Patients with very‐high‐risk prostate cancer (VHRPCa) have earlier biochemical recurrences (BCRs) and higher mortality rates. It remains unknown whether extended robot‐assisted laparoscopic prostatectomy (eRALP) without neoadjuvant or adjuvant therapy can improve the outcomes of VHRPCa patients. We aimed to determine the feasibility and efficacy of eRALP as a form of monotherapy for VHRPCa. Methods Data from 76 men who were treated with eRALP without neoadjuvant/adjuvant therapy were analyzed. eRALP was performed using an extrafascial approach. Extended pelvic lymph node (LN) dissection (ePLND) included nodes above the external iliac axis, in the obturator fossa, and around the internal iliac artery up to the ureter. The outcome measures were BCR, treatment failure (defined as when the prostate‐specific antigen level did not decrease to <0.1 ng/ml postoperatively), and urinary continence (UC). Kaplan–Meier, logistic regression, and Cox proportional‐hazards model were used to analyze the data. Results The median operative time was 246 min, and median blood loss was 50 ml. Twenty‐one patients experienced postoperative complications. Median follow‐up was 25.2 months; 19.7% of patients had treatment failure. Three‐year, BCR‐free survival rate was 62.0%. Castration‐resistant prostate cancer‐free survival rate was 86.1%. Overall survival was 100%. In 55 patients who had complete postoperative UC data, 47 patients (85.5%) recovered from their UC within 12 months. Clinical stage cT3b was an independent preoperative treatment failure predictor (p = 0.035), and node positivity was an independent BCR predictor (p = 0.037). The small sample size and retrospective nature limited the study. Conclusions This approach was safe and produced acceptable UC‐recovery rates. Preoperative seminal vesicle invasion is associated with treatment failure, and pathological LN metastases are associated with BCR. Therefore, our results may help informed decisions about neoadjuvant or adjuvant therapies in VHRPCa cases. Precis Extended robot‐assisted laparoscopic prostatectomy and extended pelvic lymph node dissection without adjuvant therapy is safe and effective for some patients with very‐high‐risk prostate cancer. The clinical stage and node positivity status predicted monotherapy failure, which may indicate good adjuvant therapy candidate.

Advanced age is an independent prognostic factor of disease progression in high-risk prostate cancer: results in 180 patients treated with robot-assisted radical prostatectomy and extended pelvic lymph node dissection in a tertiary referral center

“…Contemporary literature confirms that early biochemical recurrence and disease progression is predicted by well-known standard factors that define the inclusion criteria for high-risk patients; consequently, as the number of preoperative risk factors increases, the risk of disease progression increases [ 10 – 12 ]. When an appropriate anatomical staging of pelvic nodes has been performed, PLNI is an independent predictor of biochemical recurrence and disease progression [ 13 , 14 ]. Our study shows that, in a population of high-risk PCa undergoing surgery, the strongest independent prognostic factors of disease progression were PLNI, which was clinically predicted by well-validated prognostic factors including PSA > 20 ng/mL, adverse tumor stage (cT2/3) and grade (ISUP 4/5).…”

The survival benefit of different lymph node yields in radical prostatectomy for pN1M0 prostate cancer patients: Implications from a population-based study

“…The therapeutic role of extended LND to remove occult micrometastases in PCa patients undergoing RP probably existed ( 9 ); due to the low incidence of lymph node metastases in RP, populations in the studies were relatively small. Moreover, EAU risk stratification based on D’Amico stratification was commonly applied for stratifying patients who received extended LND or limited LND ( 15 , 16 ); this stratification system was mainly predicting biochemical recurrence, and its prognostic utility may be weak. It was obvious that the extent of LND was meaningless for lymph node-negative patients; LND aimed to eliminate the cancerous lymph node.…”