Oncologic Outcomes of Robotic-Assisted Radical Prostatectomy: The “Balancing Act” of Achieving Cancer Control and Minimizing Collateral Damage

Abstract

Oncologic outcomes after robotic-assisted radical prostatectomy (RARP) are surrogated by biochemical recurrence (BCR), itself influenced to some extent by positive surgical margin (PSM) rates. In this chapter, we will review the oncologic outcomes after RARP, focusing on margin rates which are the outcome most immediately accessible and the one directly under the surgeon’s control. We will report our own multi-institutional series examining PSM and BCR in RARP cohorts. The balancing act all RARP surgeons must perform is to maintain oncologic outcomes while minimizing collateral damage and its consequent impact on urinary continence and erectile function. Lowering PSM rates almost always comes at the expense of increasing collateral damage, and hence it is crucial to interrogate the impact PSM have on well-established oncologic parameters like BCR. Finally, not all PSM are the same and the length and location of any PSM appear to be important, with significant differences between RARP and open RP. We conclude that for low-risk patients nerve sparing to optimize functional outcomes may take priority over reducing PSM; surgeons might accept small PSMs and those in the posterolateral region. However, for high-risk cases it might be more important to get a negative surgical margin (or at least a short PSM or a nonapical PSM) than minimize collateral damage.