Outcomes of Salvage Robot-assisted Radical Prostatectomy After Focal Ablation for Prostate Cancer in Comparison to Primary Robot-assisted Radical Prostatectomy: A Matched Analysis

Background: Focal therapy (FT) for prostate cancer is less invasive than radical treat-ment but carries a risk of recurrence. Salvage robot-assisted radical prostatectomy (S-RARP) is a possible option after FT failure.Objective: To evaluate the impact of FT on functional and oncological outcomes follow-ing S-RARP.Design, setting, and participants: In a retrospective analysis of data from a prospectively collected institutional database, 53 patients who underwent S-RARP following failure of focal ablation were selected as group I; patients who had whole-gland ablation and external beam therapy were excluded. This group was matched to a control sample (matched at ratios of 1:1, 1:2, 1:3, 1:4) of men who had undergone primary RARP, using age, prostate-specific antigen (PSA), PSA density, body mass index, Sexual Health Inventory for Men score, American Urological Association symptom score, Charlson comorbidity index, prostate weight, preoperative Gleason score (GS), and history of smoking as variables.Surgical procedure: S-RARP after FT was performed using a standardized technique developed at our institute with the da Vinci Xi Surgical System.Measurements: Oncological and functional outcomes were compared between the S-RARP and primary RARP groups.Results and limitations: There was no difference in estimated blood loss (p = 0.8) between the 1:1 matched groups, but operating room time was significantly longer for S-RARP (p = 0.007). The primary RARP group had a higher proportion of patients who underwent a full nerve-sparing procedure. The S-RARP group had higher incidence of positive surgical margins (40% vs 15%; p = 0.008), GS >= 8 (25% vs 15%; p = 0.07), and positive lymph node status (9.4% vs 5.7%; p = 0.02). There was no significant difference in overall complications between the groups. The primary RARP group had a higher inci-dence of lymphocele drainage after surgery (15% vs 0%; p = 0.006). The main limitation of the study is its retrospective design.Conclusions: S-RALP after FT failure is feasible; however, surgery following FT leads to poorer oncological and functional outcomes. Despite the targeted nature of FT, significant nonfocal collateral damage is evident in tissues surrounding the prostate, which in turn translates to poorer functional outcomes after S-RARP. Patient summary: We studied the surgical challenges during robot-assisted removal of the prostate after previous focal treatment (FT) for prostate cancer and compared the outcomes to those for robot-assisted prostate removal in patients who had no previous FT. We found that this technique is safe and effective with a limited risk of complica-tions, but poor urinary and sexual functional outcomes.(c) 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.