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

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Abstract

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.

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Abbreviations

HIFU:

High-intensity focused ultrasound

RT:

Radiotherapy

Cap:

Prostate cancer

BCR:

Biochemical recurrence

FGA:

Focal gland ablation

WGA:

Whole-gland ablation

SRARP:

Salvage robot-assisted radical prostatectomy

f-SRARP:

Salvage robot-assisted radical prostatectomy post-focal therapy

wg-SRARP:

Salvage robot-assisted radical prostatectomy post-whole-gland ablation

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Authors and Affiliations

  1. AdventHealth Orlando, Orlando, USA

    K. R. Seetharam Bhat, Marcio Covas Moschovas & Vipul R. Patel

  2. SUNY Upstate Medical University, Syracuse, NY, 13502, USA

    K. R. Seetharam Bhat

  3. University College London Hospitals NHS Foundation Trust, London, UK

    Arjun Nathan & Senthil Nathan

Authors
  1. K. R. Seetharam Bhat
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  2. Arjun Nathan
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  3. Marcio Covas Moschovas
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  4. Senthil Nathan
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  5. Vipul R. Patel
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Contributions

Conception and design: KRSB, VRP. Acquisition of data: AN, KRSB. Analysis and interpretation of data: KRSB, MCM. Drafting of the manuscript: KRSB, MCM. Critical revision of the manuscript for important intellectual content: SN, VRP. Statistical analysis: KRSB. Supervision: SN, VRP.

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Correspondence to K. R. Seetharam Bhat.

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According to the International Committee of Medical Journal Editors conflict of interest (ICMJE), the authors declare that they have no conflict of interest or competing financial interests related to the manuscript. Dr. Vipul Patel is a consultant for Exact Sciences/Genomic Health, Decipher/Genomic DX, Active Surgical, and AVRA.

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Bhat, K.R.S., Nathan, A., Moschovas, M.C. et al. Outcomes of salvage robot-assisted radical prostatectomy in patients who had primary focal versus whole-gland ablation: a multicentric study. J Robotic Surg 17, 2995–3003 (2023). https://doi.org/10.1007/s11701-023-01738-0

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