Preliminary Analysis of the Feasibility and Safety of Salvage Robot-Assisted Radical Prostatectomy After Radiation Failure: Multi-Institutional Perioperative and Short-Term Functional Outcomes

Abstract

Background and Purpose:

Open radical prostatectomy after radiation treatment failure for prostate cancer is associated with significant morbidity. The purpose of the study is to report multi-institutional experiences while performing salvage robot-assisted radical prostatectomy (sRARP).

Patients and Methods:

We retrospectively identified 15 patients with biopsy-proven prostate cancer after definitive radiotherapy who underwent sRARP in three academic institutions over a 20-month period. Continence was defined as the use of 0 pads after surgery. Potency was defined as the ability to achieve erections adequate enough for penetration with or without the use of phosphodiesterase-5 inhibitors. Biochemical recurrence after sRARP was defined as a prostate-specific antigen value of >0.2 ng/mL.

Results:

Radiation treatment consisted of external-beam radiation therapy (XRT) in five cases, interstitial radioactive 125-iodine brachytherapy (BT) in five cases, proton beam therapy in two cases, and XRT followed by interstitial radioactive 125-iodine BT in three cases. The median operative time, the median estimated blood loss, and the median length of hospital stay were 140.5 min (interquartile range [IQR] 97.5–157 min), 75 mL (IQR 50–100 mL), and 1 day (IQR 1–2 d), respectively. There were no rectal injuries. Two (13.3%) patients had a positive surgical margin. A total of three (20%) patients had postoperative complications. One patient had a deep vein thrombosis (Clavien grade II), one had wound infection (Clavien grade II), and one patient had an anastomotic leak (Clavien gradeId). An anastomotic stricture (Clavien grade IIIa) later developed in this same patient, which was managed by direct visual internal urethrotomy. Of the patients, 71.4% were continent. At a median follow-up of 4.6 months (IQR 3–9.75 mos), four (28.6%) patients presented with biochemical recurrence after sRARP.

Conclusions:

The challenge during sRALP is the presence of extensive fibrosis and loss of dissection planes secondary to radiation therapy. It is a technically challenging but feasible procedure. The early complication rates were low, and early continence rates are encouraging.

Introduction

E ver since Pasteau and Degrais pioneered the use of ionizing radiation for the treatment of patients with prostate cancer in 1907, reports of improved survival and tumor control established radiotherapy (RT) as an accepted treatment modality for localized prostate cancer.^1,2 It has been estimated, however, that as many as 60% of men who undergo definitive RT for prostate cancer may experience a biochemical recurrence (BCR) as a result of local recurrences or distant metastases.³ It has been reported further that 72% of patients who have biochemical recurrence and negative metastatic evaluation after RT have a positive prostate biopsy.⁴ Such patients who have recurrent prostate cancer pose a therapeutic dilemma for the urologist. The treatment options for local recurrences at this point have been limited to brachytherapy (BT), cryotherapy, high-intensity focused ultrasound, androgen deprivation therapy (ADT), or salvage prostatectomy.

Grossfeld and associates⁵ have reported in their study from the CaPSURE database that 92% of the patients who had radiorecurrent prostate cancer received systemic ADT while 2% of the patients underwent salvage radical prostatectomy. The loss of dissection planes as a result of ionizing radiation make salvage prostatectomy a very technically challenging procedure. As a result, salvage prostatectomies have been associated with significant morbidity, with rectal injury reported as high as 35%, urinary incontinence rates up to 67%, and bladder neck contracture being reported as high as 28% in open series.^6
–8 Nevertheless, over the past decade, salvage open radical prostatectomies (sRP) has been used with increasing success.

The feasibility of performing salvage prostatectomies has been extended into laparoscopy, and more recently into robotic platforms.^9,10 RARP is the most commonly performed surgical procedure for the treatment of patients with clinically localized prostate cancer within the United States. The robot offers several advantages, such as three-dimensional (3D) vision, wristed instrumentation, motion scaling, 10× magnification, tremor filtration, etc., and has the potential to improve the outcomes after sRARP. Very few cases of sRARP have been reported in literature, however, and hence, it is an emerging area of interest. The purpose of this study is to report a multi-institutional experience while performing sRARPs and report the perioperative and short-term functional and oncologic outcomes of the procedure.

Patients and Methods

Data collection

We identified 15 men at three high-volume academic institutions who underwent sRARP over a 20-month period by three experienced surgeons (VRP, TEA, EC). These institutions include the Departments of Urology at Global Robotics Institute: University of Central Florida (11 cases), University of California–Irvine (2 cases), and Mayo Clinic, Arizona (2 cases). Institutional Review Board approval was obtained at the respective centers, and data were collected by performing chart reviews. Biochemical failure after irradiation was defined according to the American Society for Therapeutic Radiation and Oncology criteria as a prostate-specific antigen (PSA) value of 2.0 ng/mL greater than the absolute nadir. All patients underwent physical examination, serum PSA testing, CT of the abdomen and pelvis, and bone scan to rule out distant metastases before offering sRARP as a treatment option. Patients were considered candidates for surgery if they had biopsy-proven recurrent prostate cancer that was associated with an increasing serum PSA level.

Patients were followed up regularly at 3, 6, and 12 months after surgery using self-administered validated questionnaires. Continence was defined as the “use of no pads” on Expanded Prostate Cancer Index Composite questionnaire. Postoperative potency was defined using Internationan Index of Erectile Function-5 questionnaire as erections adequate enough for sexual intercourse with or without the assistance of phosphodiesterase (PDE)-5 inhibitors. BCR after sRARP was defined as a PSA level of >0.2 ng/mL.

Surgical technique

All sRARP cases were performed using a previously described six-port transperitoneal technique.¹¹ All patients were administered a single intravenous dose of a first-generation cephalosporin and 5000 U of low molecular weight heparin (5000 IU subcutaneously 2 hours before surgery and every 12 hours until hospital discharge). At the conclusion of the prostatectomy and before urethrovesical anastomosis, the integrity of the rectal wall was assessed by all three centers in a similar three-step fashion. The primary examination was performed by inspecting the anterior rectal wall under 10X magnification and 3D vision of the da Vinci surgical system (Fig. 1a). Secondary examination was performed by filling the pelvic cavity with normal saline while insufflating the rectal tube (Fig. 1b). The absence of bubbles signified no major air jet from the rectum.

FIG. 1.

(a) Primary examination of anterior surface of rectum after RARP. Rectal fibers (RF) and intense fibrosis (IF) are clearly seen. PT=pubic tubercle; PR=pubic rami; LA=levator ani; U=urethra. (b) Secondary examination: Pelvic cavity (PC) filled with physiologic saline while air is infused into the rectum via sigmoidoscope to examine for air bubbles to assess the integrity of the rectal wall. No bubbles seen. PR=pubic rami. (c) Tertiary examination of rectal integrity with sigmoidoscopy: To look for significant thinning of rectal wall and potential breach of integrity. Transilluminance signifies significant rectal wall thinning (RWT). It was repaired in a three-layer fashion using 3-0 poliglecaprone on a RB1 needle. PT=pubic tubercle; PR=pubic rami.

The tertiary examination was the transillumination test. In this test, a flexible sigmoidoscope was inserted into the rectum while at the same the time, the robotic camera light was turned off. Any transilluminance suggests a thinning of the rectal wall (Fig. 1c). Any thinning, if noticed was corrected in a three-layer fashion using a 3-0 poliglecaprone suture on an RB-1 needle (Ethicon, Inc, Somerville, NJ).

In all, 12 patients underwent a limited pelvic lymph node dissection while in two patients, unilateral nerve-sparing surgery was performed. Cystography was performed in all the patients before catheter removal. In case of any evidence of extravasation, the catheter was left indwelling, until repeated cystography showed no evidence of leak.

Results

Baseline patient characteristics

Radiation treatment consisted of external-beam radiation therapy (XRT) in five cases, interstitial radioactive 125-iodine BT in five cases, proton-beam therapy (PBT) in two cases, and XRT followed by interstitial radioactive 125-iodine BT in three cases. sRARP was performed in 15 men with a median age of 62 years (interquartile range [IQR] 55.5–65) for radiorecurrent prostate cancer over a period of 20 months (Table 1). The median body mass index and PSA level were 26.5 kg/m² (IQR 27–27.45) and 6.9 ng/mL (IQR 4.75–9.6), respectively. The median preoperative Sexual Health Inventory for Men (SHIM) and American Urological Association scores were 5 (IQR 5–10.3) and 12 (IQR 9–14), respectively.

Table 1.

Patient Characteristics

Patient	Age (yr)	BMI (kg/m ² )	Type of radiation therapy	Preradiation PSA (ng/ml)	Preradiation Gleason	Time to failure (mos)	Preoperative SHIM	Preoperative AUA	Preoperative clinical stage	PSA at failure (ng/ml)	Preoperative Gleason	Time elapsed from RT to sRALP (mos)
1	55	28.7	BT	8.70	3+3	79.7	17	4	cT1c	5.5	3+4	85.5
2	52	28	XRT+BT	19.70	4+3	37	4	13	cT2b	23	4+3	43
3	73	25.2	PBT	15.30	3+4	51.4	5	10	cT2b	3.3	4+3	51.4
4	54	26	BT	4.20	3+3	24	15	19	cT1c	4.6	3+4	30
5	61	30	BT	3.00	3+3	17	13	21	cT1c	3.3	3+4	22
6	56	29	BT	7.90	3+4	9	5	7	cT1c	3.6	3+4	12
7	63	24	XRT	11.00	3+4	12	5	22	cT1c	4.2	4+4	17
8	59	27	BT	5.00	3+3	22	12	12	cT1c	6.7	3+4	33
9	66	28	XRT	4.50	3+3	27	4	13	cT2a	2	3+4	48
10	64	28	XRT	6.30	3+4	12	4	9	cT1c	2.1	3+4	30
11	70	32	XRT	6.70	3+4	24	5	11	cT1c	4.3	4+4	32
12	71	27	PBT	4.20	3+4	28	5	9	cT1c	3.3	4+4	30.6
13	64	26	XRT+BT	10.50	3+4	120	5	13	cT1c	2	3+3	120
14	62	27.6	XRT+BT	6.90	3+4	9.83	5	15	cT1c	3	3+4	15.7
15	54	26	XRT	7.2	3+3	NA	NA	1	cT1c	10	3+4	31
Median	62	26.5	-	6.9	3+4	24	5	12	-	3.6	3+4	31.3

BMI=body mass index; PSA=prostate-specific antigen; SHIM=Sexual Health Inventory for Men; AUA=American Urological Association; RT=radiation therapy; sRALP=salvage robot-assisted laparoscopic prostatectomy; BT=brachytherapy; XRT=external-beam radiation therapy; PBT=proton-beam therapy; NA=not available.

The median interval from RT to biochemical failure was 24 months (IQR 13.25–34.75 mos), and there was a median lag time of 31.3 months (IQR 24–46.8) between the diagnosis of radiorecurrent prostate cancer and the sRARP being performed. Five patients were placed on ADT during this time interval.

Perioperative outcomes and complications

Two patients underwent a unilateral nerve-sparing salvage procedure (Table 2). The median operative time, the median estimated blood loss (EBL), and the median hospital length of stay were 138 minutes (IQR 95–159), 75 mL (IQR 50–100), and 1 day (IQR 1–1.75), respectively. The mean duration of catheterization time was 10.8 days (range 7–19). Five patients had previous abdominal surgeries and needed lysis of adhesions before prostatectomy. There were no rectal or ureteral injuries. None of the patients needed any blood transfusion or open/laparoscopic conversions.

Table 2.

Perioperative Outcomes

Patient	Operative time (min)	Nerve sparing	EBL (mL)	Complications	Length of hospital stay (d)
1	NA	UL	75	None	1
2	210	NNS	50	None	1.5
3	NA	UL	75	Deep vein thrombosis	1
4	155	NNS	50	None	2
5	189	NNS	50	None	1
6	143	NNS	50	None	2
7	100	NNS	100	Leak, urinary stricture	2
8	159	NNS	50	None	1
9	100	NNS	100	Wound infection	1
10	95	NNS	50	None	1
11	89	NNS	50	None	1
12	90	NNS	100	None	2
13	138	NNS	100	None	1
14	65	NNS	100	None	1
15	175	NNS	100	None	1
Median	138	-	75	-	1

EBL=estimated blood loss; NA=not available; UL = unilateral; NNS = non-nerve sparing.

A total of three (20%) patients had postoperative complications. One patient had a deep vein thrombosis (Clavien grade II) that was managed with anticoagulation; one patient had trocar wound infection (Clavien grade II) and was treated by antibiotics. One patient had an anastomotic leak (Clavien grade Id) and was treated by extended Foley catheterization until day 19. An anastomotic stricture developed in this same patient (Clavien grade IIIa) at 6 months; the patient was treated by direct visual internal urethrotomy.

Oncologic outcomes

On histopathologic evaluation, eight (61.5%) patients had extracapsular extension while two (15.4%) patients had seminal vesicle invasion (Table 3). Two (13.3%) patients had a positive surgical margin (PSM) in our series; both patients presented with extraprostatic disease. The median lymph node yield was 6 (IQR 4.5–7) and one (6.7%) patient showed tevidence of lymph node metastasis. Follow-up was not available for this patient, because he was very recent. At a median follow-up of 4.6 months (IQR 3–9.75), four (28.6%) patients presented with biochemical recurrence. These four patients had negative surgical margins and underwent bilateral pelvic lymph node dissection, which revealed no evidence of malignancy.

Table 3.

Oncologic And Continence Outcomes

Patient	Lymph nodes positive	Lymph nodes taken	Post-RALP stage	Post-RALP Gleason	% tumor volume	Gland Size (gm)	PSM	Follow up (mo)	PSA at maximum follow up (ng/ml)	Number of pads ^a	Time to achieve continence (mos)
1	0	0	pT3a	3+4	10	48.5	0	3.0	0.10	0	3
2	0	8	pT3b	5+3	70	NA	Yes	10.0	0.10	0	6
3	0	0	NA^b	4+4	15	29	0	5.2	0.04	1	NA
4	0	7	pT2	3+4	10	15	0	9.0	0.10	0	9
5	0	6	pT3a	3+4	25	30	0	12.0	0.10	0	12
6	0	5	pT2b	4+4	40	35	0	3.0	0.10	0	3
7	0	6	pT3a	4+4	35	20	0	6.0	0.50	0	6
8	0	8	pT3a	3+4	20	30	0	3.0	0.20	0	1
9	0	7	pT3a	3+4	35	15	Yes	3.0	0.20	0	1
10	0	7	pT3a	4+4	30	25	0	12.0	0.40	2	NA
11	0	7	pT3b	4+4	45	25	0	3.0	2.00	0	3
12	0	5	pT3a	3+4	40	52	0	3.6	2.90	3	NA
13	0	0	pT3a	4+3	30	29	0	24.0	0.10	1	NA
14	0	4	NA^b	3+4	20	34	0	4.0	0.04	0	3
15	2	6	pT2b	4+4	30	38	0	NA	NA	NA	NA
Median	1/15	6	-	3+4	30	29.5	2/15	4.6	10/14	11/14	-

For incontinent patients, number of pads is reported at maximum follow-up.

Extensive scarring made accurate T staging impossible to perform.

RALP=robot-assisted laparoscopic prostatectomy; PSM=positive surgical margin; PSA=prostate-specific antigen; NA=not available.

Functional outcomes

In our series, 10/14 (71.4%) patients were continent, defined as using 0 pads per day. The median time to achieve continence was 3 months (IQR 3–6). When stratifying these patients according to age, 5/5 (100%) patients who were younger than 60 years were continent while 5/7 (71.4%) patients between 61 and 70 years were continent. No patient (0/2) older than 70 years was continent. None of the patients in our series were potent after sRARP. However, 10/15 patients had severe erectile dysfunction (ED) before surgery (SHIM <8), three had mild to moderate ED (SHIM 12–16), while 1 patient had mild ED (SHIM 17–21) before surgery. The preoperative SHIM score was not available for one patient.

Discussion

Radiorecurrent prostate cancer can have a profound effect on a patient's quality of life, and it may be more severe than at the time of the initial cancer diagnosis. If left untreated, it can show locoregional progression, leading to distant metastases and cancer-specific death. For these reasons, controlling radiorecurrent prostate cancer after initial treatment failure is extremely crucial. The loss of dissection planes from extensive scarring postradiation, however, makes salvage prostatectomy a very technically challenging procedure. Notwithstanding, several urologists have performed sRP and have shown varying degrees of success.

Ahlering and associates¹² reported their experience with 34 patients who underwent sRP along with ADT for radioresistant prostatic adenocarcinoma. In their series, sRP was performed on 11 patients (5 after XRT and 6 after BT), with no major perioperative or postoperative complications, while 36.4% of the patients were continent. Combined with 23 other patients who underwent cystoprostatectomy, the authors reported 22 (65%) patients at a mean follow-up of 53 months who were alive and free from radiographically evident disease. Five (14.7%) patients either had radiographically evident disease or elevated PSA levels while seven (20.5%) were dead from disease.

Subsequently, Ward and colleagues¹³ presented their 30-year experience with performing sRP. They retrospectively reviewed 138 patients (127 XRT, 10 BT, 1 XRT+BT) with a median follow-up of 6.4 years and assessed the progression-free survival (PFS) and the cancer-specific survival (CSS). The median PFS for these patients was 8.7 years, and the 10-year CSS was 77%. On Cox proportional regression analysis, Gleason % 4/5 greater than 50% (odds ratio [OR] 1.62, confidence interval [CI] 1.06–2.57) and preoperative PSA value >10 ng/mL (OR 1.88, CI 1.20 to 2.90) were predictive factors for PFS while pathologic stage T₃/T₄ (OR 3.18, CI 1.02–18.13) were predictive for CSS. The incidence of rectal injuries and PSMs in their cohort was 4% and 26%, respectively, while bladder neck contracture was the most frequent complication (22%). The continence was assessed using self-administered questionnaires and was defined as the use of 0 pads or a security pad that is seldom moist, and was reported to be 56% at 12 months.

Recently, Gotto and coworkers¹⁴ reviewed 98 (64 XRT, 21 BT, 13 XRT+BT) patients who underwent sRP with a median follow-up of 34.5 months. The authors reported that 34% of patients had to visit the emergency department while 13% were readmitted to the hospital. Twenty-six percent had medical complications while 52% had surgical complications. On multivariate logistic regression analysis, the patients who underwent salvage surgery were at higher risk for urinary tract infection, bladder neck contracture, urinary retention, urinary fistula, absces and rectal injury. The authors also reported a significant association between rectal injury and subsequent urinary fistula after salvage prostatectomy. Of nine patients who had a rectal injury, a urinary fistula developed subsequently in two (22%) of them, while of 89 patients who did not have a rectal injury, a urinary fistula developed in only 2 (2%) (P=0.041). No such association was noted in patients who underwent a non-sRP. The authors further reported that one of the four preoperatively potent patients who had bilateral nerve-sparing surgery achieved erections adequate for penetration using PDE-5 inhibitors while 30% of the preoperatively continent patients needed no pads 3 years after surgery (95% CI 19–41). The group had earlier reported their series of 100 different groups of patients (58 XRT, 42 BT) with a 5-year pad-free continence rate of 39%.¹⁵

The largest series for salvage laparoscopic radical prostatectomy after radiation has been reported by Nunez-Mora and associates¹⁶ consisting of nine patients (4 XRT; 5 BT). The mean operative time was 170 minutes while the mean EBL was 250 mL. There were no open conversions, and none of the patients needed blood transfusion. There were no rectal or ureteral injuries, and the mean catheterization time was 14 days. The PSM rate was 22.2%. At a minimum follow-up of 15 months, three (33.3%) patients were pad free. The authors further reported that one of five preoperatively potent patients achieved erection 16 months after the surgery. The definition of potency (both preoperative and postoperative), however, was not clearly defined by the authors. Complications developed in two (22.2%) patients after surgery: One patient presented with gross hematuria 1 month after surgery and was treated with catheterization and bladder washout. A symptomatic lymphocele on the left side developed in another patient who needed percutaneous drainage after surgery.

The first robotic series was reported by Kaouk and colleagues¹⁰ in which four patients underwent sRARPs (2 BT; 2 XRT+BT) with a mean operative time and EBL of 125 minutes and 117 mL, respectively. All patients had obturator lymph node dissection, and none revealed any lymph node metastasis. The intraoperative course was uneventful, but PSM occurred in two patients. At 1-month follow-up, 3/4 patients used only one pad that was primarily for security and were dry on most days (Table 4).

Table 4.

Salvage Robot-Assisted Laparoscopic Prostatectomy Series

Series	N	Type of radiation	Mean follow-up (mos)	Mean EBL (ml)	Mean OR time (min)	Mean days on catheter	Mean hospital stay (d)	NS	PSM	Rectal injury	Overall complication	+LN	Continence	Potency
Kaouk 2007¹⁰	4	2 Brachy 2 XRT+BT	5	117	125	15	2.7	0/4	2/4	0	1/5	0	3/4	NA
Jamal 2008²²	1	XRT	3	100	150	14	1	0	0	0	0	0	1/1	NA
Boris 2008¹⁷	11	6 BT4 XRT 1 XRT+BT	20.5	113	183	10.4	1.4	NA	3/11	0	2/11	2/11	8/11	2/11
Eandi 2010¹⁸	18	8 BT 8 XRT 2 PBT	18	150	156	14	2	NA	5/18	0/18	7/18	1/18	6/18	0
Strope 2010²³	6	4 XRT 2 BT	> 1yr	280	356	NA	2	1	1/6	0	3/6	0	0	0

EBL=estimated blood loss; OR=operative; NS=nerve sparing; PSM=positive surgical margin; LN=lymph node; XRT=external-beam radiation therapy; BT=brachytherapy; NA=not available; PBT=proton beam therapy.

Subsequently, Boris and coworkers¹⁷ reported 11 patients (6 BT, 4 XRT, 1 XRT+BT) who underwent sRARP with pelvic lymph node dissection. The mean operative time was 183 minutes, while the mean EBL was 113 mL. There were no intraoperative complications; however, an anastomotic leak developed in one patient necessitating extended Foley catheterization, while an anastomotic stricture developed in another patient, necessitating urethrotomy. Eight (72.7%) patients were continent (0-1 pad/d), of which six were pad free. Two patients had erections adequate for sexual intercourse.

Recently, Eandi and colleagues¹⁸ have reported the largest series of sRARPs consisting of 18 patients (8 BT, 8 XRT, 2 PBT). Median operative time, EBL and length of stay were, respectively, 2.6 h,150 mL, and 2 days. There were no rectal or ureteral injuries; however, one patient who had undergone repair of a perforated gastric ulcer experienced an enterotomy, which was repaired intraoperatively. All procedures were otherwise uneventful, and none of the patients needed transfusion of any blood products. Leak was present in six (33%) cases, of whom an anastomotic stricture developed in three. Five (28%) patients had a PSM, of whom two had organ-confined disease. One patient had lymph node metastasis. Six (33%) patients were completely continent, while all patients had ED after surgery. At a median follow-up of 18 months, 12 (67%) patients were free of biochemical progression.

Our multi-institutional series shows similar results to these open, laparoscopic, or other robotic series. Our continence rate of 78.6% is encouraging, compared with contemporary open and laparoscopic series. Although some series have shown potency to be regained after salvage surgery, we did not find a similar result. Our follow-up was shorter, however; only two patients had unilateral nerve sparing while all other patients had non–nerve-sparing surgery. One of the patients who underwent a nerve-sparing procedure had mild ED while another had severe ED before surgery. Our perioperative outcomes and postoperative complications were similar to other salvage robotic series. The upgrading of biopsy on final pathologic examination is a common occurrence, as reported in multiple studies.^19,20

Our PSM rate of 13.3% is attractive; however, similar to contemporary sRARP literature, the small sample size prevents us from making any definitive conclusions (Table 4). Furthermore, in our series, at a median follow-up of 4.6 months, four (28.6%) patients suffered a BCR of the disease. Of these, three patients had extraprostatic extension of the disease, while one patient had seminal vesicle invasion. Our results are similar to contemporary robotic series. At a median follow-up of 18 months, Eandi and associates¹⁸ reported a BCR of 33%. Similarly, Boris and coworkers¹⁷ recorded a BCR of 27.3% at a mean follow-up of 20.5 months. In a laparoscopic series, Vallancien and colleagues⁹ reported a BCR rate of 27% at a mean follow-up of 11.2 months. sRP, whether performed by open, laparoscopic, or robotic means, usually involves an aggressive tumor, which might explain the high BCR rates in such patients.

We also performed limited rather than extended lymph node dissection, which is a potential limitation of our study. It has not been demonstrated, however, whether extended lymph node dissection offers any benefit (or danger) in sRPs. Furthermore, although extended lymph node dissection might have diagnostic benefit, there is no clear evidence that such patients have any survival benefit. Recent literature favors extended lymph node dissection, but such studies have been nonrandomized and have not been validated in a salvage setting.²¹ In addition, the potential complications, such as lymphoceles, thromboembolic episodes, injuries, etc., influenced the authors to perform a limited instead of an extended lymph node dissection.

One of the limitations of this study is the small sample size of 15 patients and short-term median follow-up of 5.6 months (IQR 3–9.8 mos), which is not adequate enough to comment, especially on the oncologic outcomes. Furthermore, the study was performed over three large-volume teaching centers by very experienced surgeons. All of these centers had different technique and a wide range of surgical experience with RARPs. Hence, these results cannot be generalized to low-volume centers, and the external validation of our study is limited. The authors strongly recommend that sRARP should not be performed early in the learning curve. The postprostatectomy specimens were processed at different centers by different pathologists, which might suggest interobserver variability. Nevertheless, this multi-institutional study adds important data to the RARP literature.

Conclusion

sRALP is a technically challenging but feasible procedure. This series demonstrates low complication rates and encouraging early continence outcomes. The challenge lies in the presence of extensive fibrosis and loss of dissection planes secondary to radiation therapy. The posterior dissection must be performed carefully, and intraoperative maneuvers aiming to identify possible rectal injuries are recommended. Careful patient selection, extensive counseling regarding possible side effects of the procedure, and intraoperative proctoscopy are the key features while performing sRARP. Larger series with a longer follow-up are necessary to make definitive conclusions. However, oncologic and functional outcomes were demonstrated in our multi-institutional series.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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