Salvage Robot-assisted Radical Research Articles

Complications and outcomes of salvage robot‐assisted radical prostatectomy: a single‐institution experience

To determine the peri-operative outcomes of men undergoing salvage robot-assisted prostatectomy (RARP) and to examine the complications, functional consequences and need for additional treatments after salvage RARP. At total of 51 consecutive patients underwent salvage RARP after previous failed local therapy. Biochemical recurrence (BCR) was defined as two postoperative PSA measurements ≥0.2 ng/mL. Complications at any time postoperatively were recorded prospectively using a modified Clavien system. The Kaplan-Meier method was used for survival estimation, and regression models were used to identify the predictors of BCR or progression-free survival (PFS) and complications. The median age at salvage RARP was 68 years and a median of 68 months had elapsed from the time of primary treatment. The median follow-up was 36 months. The median operation duration was 179 min with a median estimated blood loss of 175 mL. In all, 50% of patients had pathological stage 3 disease and positive surgical margins were found in 31% of patients. The estimated 3-year BCR-free or PFS was 57%. The overall complication rate was 47%, with a 35% major complication rate (Grade III-V). Potency was maintained in 23% of preoperatively potent patients and 45% of all patients regained urinary control. No clinical variables were predictive of major complications, but all patients with postoperative bladder neck contracture were incontinent. A higher PSA level and extracapsular extension were significantly associated with BCR or progression (P < 0.01). Salvage RARP provides oncological control with potential avoidance of systemic non-curative therapy. Complication, incontinence and erectile dysfunction rates are significant but frequently correctable. This reinforces the need for proper patient counselling and selection.

Robot-Assisted Radical Prostatectomy for the Treatment of Radiation-Resistant Prostate Cancer: Surgical, Oncological and Short-Term Functional Outcomes

Objective: The objective of this study was to assess the surgical, oncological and short-term functional outcomes in patients undergoing salvage robot-assisted radical prostatectomy (SRARP) for the treatment of radiation-resistant prostate cancer. Patients and Methods: The records of 3,500 men who underwent RARP from February 2006 to July 2011 were retrospectively reviewed. All peri- and postoperative data were recorded prospectively in our database. A total of 13 patients (0.37%) who had undergone SRARP for the treatment of radiation-resistant prostate cancer were identified. Results: The primary treatment was external beam radiotherapy in 7 patients (53.8%) and brachytherapy in 6 patients (46.2%). The interval from radiotherapy to biochemical recurrence (BCR) varied from 12 to 108 months (median 48.9). Neurovascular bundle preservation was performed in 3 patients (23.1%). No intraoperative or major complications were encountered. Minor complications were encountered in 4 patients (30.7%). At 12 months, 7 patients were continent (53.8%), 3 exhibited mild incontinence (23.1%) and 3 (23.1%) were incontinent. Regarding potency, none of the patients were potent at 6 months, but 3 patients (23.1%) were potent at 1 year. Regarding BCR, 3 of the patients (23.1%) never reached a prostate-specific antigen nadir of zero, and during the follow-up period only 3 patients (23.1%) exhibited BCR. No disease-specific mortality was evident during follow-up. Conclusions: Although early in its development, it appears that SRARP is technically feasible and offers satisfactory surgical, oncological and short-term functional outcomes.

1218 SALVAGE ROBOT-ASSISTED RADICAL PROSTATECTOMY FOR RECURRENT PROSTATE CANCER: SAFETY AND FEASIBILITY

INTRODUCTION AND OBJECTIVES: The safety and feasibility of salvage robot-assisted radical prostatectomy (sRARP) for recurrent prostate cancer is unclear. Herein we report short-term cancer control, functional, and perioperative outcomes in a multi-institutional cohort. METHODS: Between July 2007 and October 2011, 38 consecutive men underwent sRARP for recurrent prostate cancer at the University of Southern California (n 14) or Global Robotics Institute (n 24). Failed primary therapy was varied (external beam radiotherapy [EBRT; n 14]; interstitial brachytherapy [IBT; n 11]; EBRT IBT [n 5]; high-intensity focused ultrasound [n 3]; cryoablation [n 3]; other [n 2]). The main outcomes were immediate biochemical failure (IBF), positive surgical margins (PSM), urinary continence and erectile function at 3 months, and complications within 90 days of surgery. Immediate biochemical failure was defined as a PSA 0.2 ng/ml. Urinary continence was defined as the use of no pads and erectile function was defined as a SHIM score 21. Complications were classified and graded using the Clavien system. RESULTS: The median age was 68 years (50-83 years) and median preoperative PSA was 4.1 ng/ml (0.4-15.2 ng/ml). Preoperative biopsy Gleason score was 6 (n 7), 7 (n 18), and 8 (n 12). All procedures were completed without the need for open conversion. No patient experienced an intra-operative complication. Median estimated blood loss was 100 ml (30-300 ml) and operative time was 1.5 h (1-6h). Median length of hospital stay was 1 day (1-7 days). The median duration of urethral catheterization was 12 days (4-48 days). IBF occurred in 9 (29%) patients and PSM occurred in 7 (18%) patients. Urinary continence and erectile function occurred in 9 (34%) and 0 patients, respectively. One or more postoperative complications occurred in 12 (31%) patients. Low grade (I-II) and high grade (III-IV) complications occurred in 8 (21%) and 4 (10%) patients, respectively. No patient died. CONCLUSIONS: Salvage robot-assisted radical prostatectomy is safe and feasible. Short-term cancer control and perioperative morbidity were acceptable.

V15 Technical challenges of salvage robotic assisted radical prostatectomy

V15 Technical challenges of salvage robotic assisted radical prostatectomy

Safety and feasibility of salvage robot-assisted radical prostatectomy for recurrent prostate cancer.

e15171 Background: The safety and feasibility of salvage robot-assisted radical prostatectomy (sRARP) for recurrent prostate cancer is unclear. Herein we report short-term cancer control, functional, and perioperative outcomes in a multi-institutional cohort. Methods: Between July 2007 and October 2011, 38 consecutive men underwent sRARP for recurrent prostate cancer at the University of Southern California (n=14) or Global Robotics Institute (n=24). Failed primary therapy was varied (external beam radiotherapy [EBRT; n=14]; interstitial brachytherapy [IBT; n=11]; EBRT + IBT [n=5]; high-intensity focused ultrasound [n=3]; cryoablation [n=3]; other [n=2]). The main outcomes were immediate biochemical failure (IBF), positive surgical margins (PSM), urinary continence and erectile function at 3 months, and complications within 90 days of surgery. Immediate biochemical failure was defined as a PSA &gt; 0.2 ng/ml. Urinary continence was defined as the use of no pads and erectile function was defined as a SHIM score &gt; 21. Complications were classified and graded using the Clavien system. Results: The median age was 68 years (50-83 years) and median preoperative PSA was 4.1 ng/ml (0.4-15.2 ng/ml). Preoperative biopsy Gleason score was ≤6 (n=7), 7 (n=18), and ≥8 (n=12). All procedures were completed without the need for open conversion. No patient experienced an intra-operative complication. Median estimated blood loss was 100 ml (30-300 ml) and operative time was 1.5 h (1-6h). Median length of hospital stay was 1 day (1-7 days). The median duration of urethral catheterization was 12 days (4-48 days). IBF occurred in 9 (29%) patients and PSM occurred in 7 (18%) patients. Urinary continence and erectile function occurred in 9 (34%) and 0 patients, respectively. One or more postoperative complications occurred in 12 (31%) patients. Low grade (I-II) and high grade (III-IV) complications occurred in 8 (21%) and 4 (10%) patients, respectively. No patient died. Conclusions: Salvage robot-assisted radical prostatectomy is safe and feasible. Short-term cancer control and perioperative morbidity were acceptable; however, functional recovery was poor. To date, this is the largest series worldwide.

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

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). 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. 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. 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.

Salvage Therapy for Radiorecurrent Prostate Cancer

Locally recurrent prostate cancer after radiation therapy, also known as radiorecurrent prostate cancer, has an unfavorable prognosis. Two-thirds of patients with radiorecurrent prostate cancer have an advanced pathological disease status by the time they undergo salvage therapy. Several salvage therapies for radiorecurrent prostate cancer are available. Salvage radical prostatectomy (SRP) and salvage cryoablation are the most feasible and effective therapies for radiorecurrent prostate cancer. Although SRP is technically more difficult and has a higher complication rate than do other salvage therapies, the procedure provides a long-term survival benefit. Preliminary studies of salvage robot-assisted radical prostatectomy (SRARP) suggest that SRARP may be similar to or at least as effective as SRP. The intermediate oncological efficacy and morbidity of salvage cryoablation are similar to those of SRP. Prognostic factors for successful salvage therapy include serum prostate-specific antigen level ≤10 ng/mL, Gleason score ≤8, and a clinical disease stage T1c or T2. Assessing the comparative oncological efficacy and complications of the available salvage therapies for radiorecurrent prostate cancer requires strict guidelines, including universal patient selection criteria and an intergrade definition of biochemical failure.

Salvage robot-assisted radical prostatectomy with pelvic lymph node dissection after cryotherapy failure.

We report the first case of post-cryotherapy salvage radical prostatectomy for local recurrence performed laparoscopically with the da Vinci robot. Total operative time was 210 minutes and blood loss was 50ml. There were no intraoperative or postoperative complications. The hospital stay was 24 hours and the Foley catheter was removed on postoperative day 7. The patient achieved a pad free status 4 weeks postoperatively. Pathology showed extensive disease, pT3bN0, Gleason score of 5+3 and positive margins. The patient continued on complete androgen deprivation therapy and his follow up PSA at 10 months was <0.1. Further studies are needed to evaluate both functional and oncological results with this approach.