Salvage robotic prostatectomy for radio recurrent prostate cancer: technical challenges and outcome analysis: Beyond the Abstract

Salvage Robotic Assisted Radical Prostatectomy (sRARP) is increasingly accepted as a treatment option in radio-recurrent prostate cancer. However, there are only a few published series outlining the technical aspects and outcomes after this procedure. The daVinci robot with its endo-wrist technology and vision magnification has facilitated the approach to complex urological procedures; it has permitted technical modifications allowing surgeons to take on more challenging cases such as sRARP. This systematic review compiles all the published series to date presenting data on sRARP and thus provides an important update for this procedure. 

The study1 includes 197 men from ten series between 2008 and 2016 who had disease relapse after receiving either radiotherapy, brachytherapy, protein beam therapy or a combination of these modalities. Perioperative details (including operative time, estimated blood loss, catheter time and length of stay) were systematically recorded along with surgical outcomes (perioperative complications including specifically rectal injury, anastomotic stricture, continence and potency) and oncological outcomes (positive surgical margin, lymph node positivity and biochemical relapse). 

Mean operative time for the combined data was not much longer than published non-salvage series at 178 minutes, catheters stayed in for a mean of 11.3 days and men stayed in hospital for 2.3 days. Estimated blood loss was only 153mls. Median follow up across the series was fairly short at 18.6 months (range 3-36 months). In terms of functional outcomes, 60% were continent at the time of follow-up, while 26% of those who had some form of nerve-sparing were potent. For oncological outcomes, 71% were cancer free at follow up.  As for complications, a real concern for this type of surgery is damage to the rectum due to scarring and adherence during dissection around the posterior prostatic planes. Despite this, only two men in these series were reported to have had rectal injuries, which is encouraging. Overall, 16% of men had complications requiring intervention (Clavien Dindo >II), including 16 bladder neck stenosis/anastomotic strictures requiring intervention..

These combined results present an encouraging picture for sRARP in terms of cancer outcomes although longer term follow up is needed to truly assess the durability of cancer control. Functional outcomes are certainly challenging. While low potency might be expected after multimodal therapy, continence rates here are markedly lower than published non-salvage series2 3 and present a hurdle to acceptance of this approach. 

Looking forwards, a larger multicentre European series is being prepared with contributions from Melbourne and other international sites. This will incorporate prospectively collected data and longer-term follow up and we anticipate will further cement sRARP as a viable option for men with radio-recurrent disease. Watch this space. 

Written by: Alastair D Lamb1, Homayoun Zargar2,3, Declan G Murphy1,3,

1Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia

2Department of Surgery, Division of Urology, Royal Melbourne Hospital and University of Melbourne, 300 Grattan St, Parkville 3052, Victoria, Australia 

3Australian Prostate Cancer Research Centre, Epworth Healthcare, Richmond, Australia


References:
1. Zargar H, Lamb AD, Rocco B, Porpiglia F, Liatsikos E, Davis J, et al. Salvage robotic prostatectomy for radio recurrent prostate cancer: technical challenges and outcome analysis. Minerva urologica e nefrologica = The Italian journal of urology and nephrology 2016.

2. Gnanapragasam VJ, Thurtle D, Srinivasan A, Volanis D, George A, Lophatananon A, et al. Evolution and oncological outcomes of a contemporary radical prostatectomy practice in a UK regional tertiary referral centre. BJU international 2016.

3. Basto MY, Vidyasagar C, te Marvelde L, Freeborn H, Birch E, Landau A, et al. Early urinary continence recovery after robot-assisted radical prostatectomy in older Australian men. BJU international 2014;114 Suppl 1:29-33.

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