Salvage robot-assisted radical prostatectomy : single surgeon experience

Aim: The objective of this study is to report the perioperative, functional and oncologic outcomes of salvage robot-assisted radical prostatectomy (sRARP). Patients and Methods: We identified 19 patients who underwent sRARP with bilateral limited pelvic lymph node dissection by a single surgeon between July 2002 and October 2010. RT consisted of XRT in nine cases, brachytherapy in seven cases, brachytherapy plus XRT in two cases and proton beam therapy in one case. Biochemical failure was defined as a PSA of >2.0 ng/ml over the absolute nadir. Continence was defined as the use of ‘no pads’ after surgery and potency was defined as the ability to achieve and maintain adequate erection for penetration, with or without PDE-5 inhibitors. Biochemical recurrence (BCR) was defined as a PSA of >0.2 ng/ml after sRARP. Results: The median (IQR) age, BMI, SHIM score and AUA score were 66 (range: 60-70.5) years, 30 (range: 37-32.5) kg/m2, 5 (range: 4- 15), and 12 (range: 7.5-13), respectively. The median PSA nadir after RT and the median PSA before surgery were 4.3 (range: 3.4-4.9) and 1.2 (range: 0.75-1.2) ng/ml, respectively. Six patients were placed on ADT. The median OR time and blood loss were 92.5 (range: 90-107.5) min and 100 (range: 100-100) ml, respectively. A partial nerve-sparing surgery was performed in five (26.3%) patients, while all other patients underwent non nerve-sparing surgery. On histopathological evaluation, five patients (26.3%) had pT2 disease, eight (42.1%) had pT3a, while five (26.3%) had pT3b. Due to intense scarring, it was not feasible to accurately stage one prostate. Three patients (15.8%) had a positive surgical margin. The median Gleason score, prostate weight and tumor volume were 8 (range: 7-8), 34 (range: 25-43) g and 25% (range: 16-32%), respectively. The median length of hospital stay and days on catheter were 1 (range: 1-2) day and 8 (range: 7-11) days, respectively. Two (10.5%) patients had three complications (15.8%). Two patients had anastomosis leak (1d), both treated by extended Foley’s catheterization. One of these developed an anastomotic stricture (Clavien 3a) at six months and was treated by direct internal urethrotomy. There were no rectal injuries or bladder neck contractures. Fifteen patients had at least six months of follow-up, of whom twelve (80%) were continent. The median time to achieve continence was 5.5 (range: 2.6-9) months. Only two patients who had partial nerve-sparing surgery had six months of follow-up, and none of them were potent. On a median followup of 24 (range: 6-45) months, 4 patients (21%) had BCR. Conclusion: sRALP is a technically challenging but feasible procedure. The challenge lies in extensive fibrosis and loss of dissection planes, secondary to radiation therapy. This is the largest published single surgeon series and it shows encouraging perioperative, continence and oncologic outcomes.