THE ROLE OF ROBOT-ASSISTED RADICAL PROSTATECTOMY AND EXTENDED PELVIC LYMPH NODE DISSECTION IN PATIENTS WITH LOCALLY ADVANCED PROSTATE CANCER: RESULTS FROM A MULTI-INSTITUTIONAL SERIES

INTRODUCTION & OBJECTIVES: Previous studies demonstrated that Robot-Assisted Radical Prostatectomy (RARP) might represent an oncologically safe option in patients with high-risk Prostate Cancer (PCa). However, none of these investigations focused on men with locally advanced disease (i.e., clinical stage T3 or greater). The aim of our study was to assess the safety and effectiveness of RARP in patients with locally advanced PCa treated at three high-volume European institutions. MATERIAL & METHODS: Overall, 94 patients with locally advanced disease defined by clinical stage ≥T3 undergoing RARP with extended pelvic lymph node dissection at three referral institutions between 2011 and 2015 were evaluated. Perioperative outcomes consisted of operative time, blood loss, Length of hospital Stay (LoS), and postoperative complications (categorized according to the Clavien-Dindo classification). Biochemical Recurrence (BCR) was defined as two consecutive PSA ≥0.2 ng/ml. Clinical recurrence was defined as the onset of metastases during follow-up. KaplanMeier analyses assessed time to BCR and clinical recurrence. Multivariable Cox regression analyses were performed to assess the predictors of recurrence. RESULTS: Median (IQR) age at surgery was 64.3 years. Median preoperative PSA was 9.7 ng/ml. Biopsy Gleason score was 6, 7, and 8-10 in 18 (19.1%), 51 (54.3%), and 25 (26.6%) patients, respectively. Overall, median operative time, blood loss and LoS were 230 min, 200 ml, and 6 days, respectively. Overall, 12 (12.7%) patients experienced postoperative complications. Overall, 5 (5.3%), 4 (4.3%), 2 (2.1%), and 1 (1.1%) patients had a Clavien I, II, III, and IV complications. Overall, 22 (23.4%), 31 (33.0%), 40 (42.6%), 1 (1.1%), and 35 (37.2%) patients had T2, T3a, ≥T3b, pT4, and pN1 disease, respectively. Overall, 30 (32.3%) patients had positive surgical margins. The median number of nodes removed was 16. Overall, 19 (20.2%) and 21 (22.3%) patients received adjuvant radiotherapy and hormonal therapy, respectively. Median (IQR) follow-up was 23.5 months. At 3-year follow-up, the BCR-free survival rate was 63.3%. In multivariable analyses, pathologic Gleason score 9-10, pathologic stage ≥T3b, and positive margins represented independent predictors of BCR (all P≤0.05). CONCLUSIONS: RARP represent a safe and effective option in patients with locally advanced PCa, where excellent oncologic outcomes are observed at short-term follow-up. In particular, two out of three patients are free from recurrence at 3 years after surgery. Pathologic stage, positive margins and Gleason score represent predictors of BCR and should be considered to select patients for multimodal approaches. Further studies with higher number of patients and longer follow-up are needed to confirm these findings.