ESOU18: Open vs Robotic Surgery for Locally Advanced Prostate Cancer: Oncological and Functional Outcomes

Amsterdam, The Netherlands ( In the current era most prostate cancers (PC) are diagnosed at an early stage, due to the introduction of PSA-based screening. However, up to 10% of newly diagnosed PCs still present with locally advanced features, suggestive of a potentially lethal disease. To date, there is no definitive consensus on the definition of locally advanced PC. Patients with locally advanced PC were historically addressed to systemic therapies, namely hormonal therapy, until recent studies demonstrated that surgery alone, or in combination with additional treatments such as radiotherapy (RT) and androgen deprivation therapy (ADT) might represent oncologically safe options, achieving high 5-yr cancer-specific survival (CSS) rates. Recent investigations have shown that robotic surgery (RARP) represents a safe and effective procedure even in the setting of these patients. 

Current studies on RARP for locally advanced PC report biochemical recurrence (BCR)-free survival (BFS) rates at 3 years ranging from 58% to 81.5%. The only comparative study between RARP and open surgery (RRP), performed on a retrospective series by Vora et al, concluded that RARP has comparable oncologic outcomes compared to RRP, especially when performed by experienced high volume surgeons.1 Good outcomes are also shown in RRP studies, which provide more reliable survival estimates due to their longer follow-up. These demonstrated 10-yrs BFS of up to 56% and 10-yrs PFS of up to 81.3%. Accordingly, CSS and overall survival (OS) exceeded 85% and 60% at 10 years, respectively. To date, no prospective comparative studies between RARP and RRP have been performed. 

A recent systematic review and meta-analysis assessed the positive surgical margins (PSM) rate of studies comparing RRP and RARP in all high-risk PC, showing a decreased risk of PSM and BCR in RARP. In a review of a comparative evaluation of PLND by surgical methods, robotic PLND achieved a similar number of nodes removed, and percentage of node positivity, to that of pure laparoscopic and open procedures. This is particularly important in the setting of locally advanced PC, where the rates of pN1 are as high as 37% and a correct lymphadenectomy is essential to achieve good cancer control.

With regards to functional outcomes, only a few studies including patients with locally advanced PC reported data on urinary continence, taking into account the lack of a standardized definition of “continence recovery”. The heterogeneity of these studies does not enable us to draw definitive conclusions on continence recovery after surgery; furthermore, it is not possible to make an adequate comparison between RARP and RRP.

As per current guidelines, a non-nerve-sparing procedure should be recommended in patients with locally advanced PC. Some of the known advantages of the robotic approach are the reduced bleeding and hospital stay. The risk of blood transfusions is much higher in RRP than in RARP. As for complications, comparative studies reported similar rates of complications among high-risk men treated with minimally invasive and open surgery. All these comparisons should be confirmed by prospective, comparative studies.

Presented by: Paolo Gontero, MD Associate Professor of Urology and  Vice-Chairmen of the Division of Urology, Department of Urology, A.O.U. San Giovanni Battista Molinette, University of Turin, Turin, Italy

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at The 15th Meeting of the EAU Section of Oncological Urology ESOU18 - January 26-28, 2018 - Amsterdam, The Netherlands

1.Vora AA, Marchalik D, Kowalczyk KJ, et al. Robotic-assisted prostatectomy and open radical retropubic prostatectomy for locally-advanced prostate cancer: multi-institution comparison of oncologic outcomes. Prostate international 2013; 1(1): 31-6.