Techniques and Outcomes of Salvage Robot-Assisted Radical Prostatectomy (sRARP) - Beyond the Abstract

Salvage robot-assisted radical prostatectomy (sRARP) is potentially a curative treatment option for patients following locally recurrent prostate cancer (PCa) after receiving whole-gland or focal treatment. However, the procedure is far less common than primary robot-assisted radical prostatectomy (RARP) and is historically associated with worse cancer and functional outcomes.1 As surgical experience and technique have improved, outcomes for sRARP have also improved.2-4



Our study reports that the robotic surgical technique needs to be amended depending on the type of primary treatment for PCa. This is to negotiate the secondary effects such as tissue adherence and loss of surgical planes induced by the primary treatment. Our "Surgery in Motion" study details the tips and tricks a surgeon can use to navigate the unique challenges associated with each primary treatment. Furthermore, our results show that by varying the surgical technique to the primary treatment, cancer and functional outcomes are acceptable given the challenging nature of the surgery. Therefore, sRARP is a feasible option in high-volume centers with adequate robotic training.

The COVID-19 pandemic has changed surgical practice worldwide. Due to concerns regarding perioperative complications, mortality, and rationing of essential resources, approximately 28 million surgeries have been delayed or canceled .5 A recent collaborative review of genito-urinary cancers suggested intermediate to high-risk PCa patients should receive androgen deprivation therapy (ADT) until the time of surgery or radiotherapy.6 Additionally, focal therapy has increased in popularity in recent years due to the reduced side-effect profile.7

Therefore, the requirement for sRARP after recurrent PCa could increase exponentially over the immediate future. It is imperative that robotic urology surgeons are rapidly taught the techniques to overcome the challenges of salvage surgery to deliver the best cancer and functional outcomes for the patient. The ORSI Academy in Belgium and the University College London Hospital (UCLH) offer structured training courses for salvage RARP.8,9

Written by: Arjun Nathan, MD, University College London Hospitals, United Kingdom

References:

  1. Rogers, Eamonn, Makoto Ohori, Vahan S. Kassabian, Thomas M. Wheeler, and Peter T. Scardino. "Salvage radical prostatectomy: outcome measured by serum prostate-specific antigen levels." The Journal of urology 153, no. 1 (1995): 104-110.
  2. Stephenson, Andrew J., Peter T. Scardino, FERNANDO J. BIANCO JR, CHRISTOPHER J. DiBLASIO, Paul A. Fearn, and James A. Eastham. "Morbidity and functional outcomes of salvage radical prostatectomy for locally recurrent prostate cancer after radiation therapy." The Journal of urology 172, no. 6 (2004): 2239-2243.
  3. Stephenson, Andrew J., and James A. Eastham. "Role of salvage radical prostatectomy for recurrent prostate cancer after radiation therapy." Journal of clinical oncology 23, no. 32 (2005): 8198-8203.
  4. Sanderson, Kristin M., David F. Penson, Jie Cai, Susan Groshen, John P. Stein, Gary Lieskovsky, and Donald G. Skinner. "Salvage radical prostatectomy: quality of life outcomes and long-term oncological control of radiorecurrent prostate cancer." The Journal of urology 176, no. 5 (2006): 2025-2032.
  5. CovidSurg Collaborative, Dmitri Nepogodiev, and Aneel Bhangu. "Elective surgery cancellations due to the COVID‐19 pandemic: global predictive modelling to inform surgical recovery plans." British Journal of Surgery (2020).
  6. Wallis, Christopher JD, Giacomo Novara, Laura Marandino, Axel Bex, Ashish M. Kamat, R. Jeffrey Karnes, Todd M. Morgan et al. "Risks from deferring treatment for genitourinary cancers: A collaborative review to aid triage and management during the COVID-19 pandemic." European Urology (2020).
  7. Ahmed, Hashim U., Richard G. Hindley, Louise Dickinson, Alex Freeman, Alex P. Kirkham, Mahua Sahu, Rebecca Scott, Clare Allen, Jan Van der Meulen, and Mark Emberton. "Focal therapy for localised unifocal and multifocal prostate cancer: a prospective development study." The lancet oncology 13, no. 6 (2012): 622-632.
  8. ORSIAcademy. 2020 [Available from: https://www.orsi-online.com/en.
  9. UCLHEducationCentre. 2020 [Available from: http://training.ucheducationcentre.org/home/viewcourse/164/.
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