381 Salvage Robotic-Assisted Laparoscopic Radical Prostatectomy a Single Institution Five-Year Experience

Abstract

Purpose-Salvage robotic-assisted laparoscopic prostatectomy (sRALP) is a treatment option for certain patients with recurrent prostate cancer (CaP) after primary therapy. Data regarding patient selection, complication rates, and cancer outcomes are scarce. Here, we report the largest, single-institution series to date of sRALP. Methods-We reviewed our database of 4,234 patients who have undergone robotic-assisted laparoscopic prostatectomy at Vanderbilt University and identified 34 men who had surgery after failure of prior definitive ablative therapy. Each patient had biopsy-proven recurrent CaP and no evidence of metastases. The primary outcome measure was biochemical failure (BCF). Results-The median time from primary therapy to sRALP was 48.5 months with a median PSA prior to sRALP of 3.86 ng/mL. Most patients had Gleason scores ≤ 7 on pre-sRALP biopsy, although 12 patients (35%) had ≥ Gleason 8 disease. After a median follow-up of 16 months, 18% had BCF. The positive margin rate was 26%, of which 33% had BCF following surgery. On univariable analysis, there was a significant association between PSA doubling time and BCF (hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.60-0.99; p=0.049) as well as between Gleason score at original diagnosis and BCF (HR 3.49, 95% CI 1.18-10.3; p=0.023). There were two Clavien II-III complications: a pulmonary embolism and a rectal laceration. Post-operatively, 39% had excellent continence. Conclusions-sRALP is safe, with many outcomes favorable to open, salvage radical prostatectomy series. Advantages include superior visualization of the posterior prostatic plane, modest blood loss, low complication rates, and short length of stay.

Current role of salvage robotic-assisted laparoscopic prostatectomy

“…Ideally patients should have minimal comorbidities (4) and a life-expectancy exceeding 10-years (5). Kaffenberger et al (16) suggest that patients with a slow PSA doubling-time (8-12 months) and low Gleason grade (≤ 6) disease at original diagnosis are more likely to benefit from sRALP. In general low-risk patients with the above mentioned features or PSA velocity <2.0ng/mL per year, time to PSA failure > 3 years or a PSA < 10 ng/mL immediately before salvage therapy are expected to have better outcomes following sRP (5).…”

“…During sRALP Boris et al (17) frequently encountered BT seeds outside the prostate and in the perineum. Kaffenberger et al (16) completely mobilised the lateral margins of the prostate which enhances the dissection and visualisation for the posterior apical dissection, an area noticeably adherent post-radiation. Chauhan et al (2) described transilluminating technique for detecting rectal injuries whereby a sigmoidoscope was inserted rectally and the robotic camera light dimmed to allow illumination of thin and potentially damaged rectal wall.…”

“…Any positive transillumination tests were sutured in three-layers (2). The only significant rectal injury in a single patient was reported in the largest series by Kaffenberger et al (16) whereby a rectal laceration required repair and diversion. Management of rectal injury is varied but most frequently a two-layered closure is advised (7).…”

“…Since sRALP is a rare, technically challenging procedure the long-term oncological outcome data is limited and the follow-up periods are varied from the few small studies in the literature [ Table 2]. Kaffenberger et al (16) have published the largest series of sRALP with some patient follow-up of up to 5-years. Their study demonstrated that on univariable analysis PSA doubling-time and original Gleason score at diagnosis had statistically significant association with biochemical failure (p=0.049 and p=0.023 respectively) (16).…”

“…Kaffenberger et al (16) have published the largest series of sRALP with some patient follow-up of up to 5-years. Their study demonstrated that on univariable analysis PSA doubling-time and original Gleason score at diagnosis had statistically significant association with biochemical failure (p=0.049 and p=0.023 respectively) (16). Biochemical failure in this study was defined as PSA 'persistence' as an initial post-sRALP PSA≥0.1 ng/mL and PSA 'recurrence' of PSA ≥0.2 ng/mL with subsequent confirmatory PSA >0.2ng/mL (16).…”