Long-Term Oncologic Outcomes of Robot-Assisted Radical Prostatectomy

Abstract

Robot-assisted radical prostatectomy is a new innovation. As a result, the long-term outcomes of this surgical approach are limited. Robotic-assisted radical prostatectomy (RARP) has become the dominant form of surgical treatment of prostate cancer in the United States. Since its introduction in early 2000s, mid- and long-term investigations are now fruition. The available literature demonstrates similar oncologic outcomes for RARP and its laparoscopic and open radical prostatectomy counterparts.

Editorial Comment: John W. Davis

Any novel procedure in oncology needs long-term follow-up. An exciting alternative to standard therapy for favorable risk disease is focal therapy using cryotherapy, laser, or other source of ablation. These represent very new techniques and deserve careful scrutiny as to their safety and efficacy. Anecdotal failures are more difficult to analyze—errors in patient selection, technique, follow-up care? Just this past month, I have diagnosed two impressive failures from focal laser ablation—one lymph node metastatic and one locally advanced. Such events happen after robotic prostatectomy as well; however, we have a full pathology report to help us understand what happened. Ultimately, robotic surgery is just a tool to accomplish what we know and have studied for decades in open surgery.

Nevertheless, long-term oncologic outcomes are important, and the Henry Ford group presents an excellent review of the long-term outcomes from this procedure that they started. I would also highlight their work as reported by Sukumar and Rogers [19]. The final cohort consisted of 4803 patients with a median 26 months follow-up—IQR 1.2–54.6. The overall biochemical recurrence rate was 9.8 %. The actuarial 8-year results were 81 % biochemical recurrence free, 98.5 % metastasis free, and 99.1 % cancer-specific survival. This is a non-comparative study that occurred at the first high volume center and included their learning curve. Nevertheless, the overall and detailed statistics provided certainly support a consistent oncologic outcome compared to open technique.

Another key recent study by Hu et al. [20] is often referred to as robotic outcomes—“2nd generation.” In a more established cohort using SEER/Medicare and propensity-based analyses, RARP had fewer positive margins than open—13.5 % versus 18.3 % and less additional cancer therapy within the first six postoperative months. If cases continue to be condensed toward fewer, high-volume referral surgeons, then perhaps oncologic control may be a benefit at this endpoint. Overall, surgeons will utilize their robotic pT2 and pT3a positive margin rates for early quality assessment. The question as to whether a pT2 Gleason 3 + 4 negative margin or any other combination of stage, grade, and margin status behaves in the exact same manner using similar definitions of failure and length of follow-up. The data presented would support this notion, although prospective controlled trials are lacking. The early pathologic staging seems satisfactory to most robotic surgeons to make a full-scale switch to the technique, compared to the dilemma of the ablative treatments that need much longer outcomes before recommending broad usage.