Assistant Professor SUNY upstate medical university
With increasing experience, surgeons worldwide have increasingly used Salvage Robotic-assisted Radical Prostatectomy as a tool to treat patients who failed previous non-surgical treatment for prostate cancer. Our study compared the outcomes of salvage radical prostatectomy from two high-volume centers from the US and UK in patients who failed prior treatment with whole gland ablation (SRARP) and focal therapy (fSRARP).
Methods: The study assessed 339 patients compared in two groups: 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.
Results: The median total operative time for fSRARP was 18 mins higher than SRARP (P <0.001). Significantly higher rates of nerve-sparing was performed in fSRARP (focal vs whole gland; bilateral – 15.2% vs 9.3%; unilateral 49% vs 28.4%; p <0.001). SRARP group had higher rates of ISUP GGp 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 fSRSRP had higher rates of ISUP GGp 4 (11.7% vs 10.7%; p<0.001) and = pT3a (64.8% vs 51.6%; p <0.001). Also, fSRARP had higher rates of positive surgical margins (26.2% vs 10.3%; p <0.001). Fig 1 shows a cox regression proportional hazard model for BCR excluding PSA persistence shows a trend towards higher postoperative BCR probability in patients who had SRARP (p= 0.534). Fig 2 shows a cox regression proportional hazard model reporting the probability of postoperative continence shows higher and faster recovery in patients who had fSPARP compared to SRARP (p=0.013). There was no difference in trends of postoperative potency probability in both groups (p=0.997). (Fig 3)
Conclusions: Salvage robotic-assisted radical prostatectomy is challenging wherein patients have adverse pathological features irrespective of primary treatment. Focal therapy group had higher rates of nerve-sparing with increased positive surgical margins. However, both groups had poor functional outcomes regardless of nerve-sparing degree, indicating significant collateral and contralateral damage to tissues surrounding the prostate. We believe that this analysis is crucial for counseling patients regarding expected outcomes before performing a salvage treatment following non surgical local therapy failure.