Salvage robotic-assisted radical prostatectomy (S-RARP) is a technically demanding procedure, often reserved for recurrent prostate cancer after primary radiotherapy or ablation therapies. Our multicenter study, conducted within the EAU Robotic Urology Section (ERUS) Scientific Working Group, represents the largest collaborative effort to date on this topic, pooling data from 397 cases across nine high-volume centers.
What makes this study particularly valuable is that it focuses exclusively on robotic-assisted surgery, avoiding the heterogeneity seen in previous studies that combined open, laparoscopic, and robotic techniques. This consistency strengthens the applicability of our results for centers specializing in robotic urologic surgery.
We demonstrated that S-RARP is feasible and safe when performed by experienced surgeons, with very low rates of intraoperative complications and major postoperative morbidity. Despite these favorable safety outcomes, functional recovery remains challenging. Continence recovery varied significantly by primary treatment modality, with focal ablation showing the highest 3-year continence rates, followed by whole-gland ablation and radiotherapy. Potency outcomes were modest across all groups but suboptimal when compared to primary prostatectomy.
Our findings reinforce that oncologic control is achievable, with 5-year biochemical recurrence rates comparable across treatment groups and 5-year overall survival exceeding 90%. Importantly, we emphasize that favorable outcomes are highly dependent on surgical expertise and patient selection, particularly in cases where anatomical distortion from prior therapies increases operative complexity. We observed better outcomes in patients who met the EAU guidelines for salvage prostatectomy. However, in real-world practice, many patients do not fit these ideal criteria. The decision-making process remains complex because the optimal salvage treatment strategy for recurrent prostate cancer is still not clearly defined.
This work also underscores the need for tailored counseling and rehabilitation protocols for patients undergoing S-RARP. With the evolution of focal therapies and increasing numbers of patients eligible for salvage interventions, robotic surgery should be considered a standard option in high-volume centers with experienced hands.
Continued refinement of guidelines based on robotic surgery data is essential, as is long-term prospective research to further guide patient selection and postoperative expectations. Future research should also focus on capturing detailed information about primary therapies, such as radiation dose, energy modality, and tumor characteristics at the time of initial treatment, as these variables critically influence salvage surgical planning and outcomes.
Written by: Marcio Covas Moschovas, MD, PhD, FACS, Adventhealth Global Robotics Institute, Kissimmee, FL, USA
Read the Abstract