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Surgery in Motion

Robot-assisted Radical Prostatectomy and Extended Pelvic Lymph Node Dissection in Patients with Locally-advanced Prostate Cancer

By: Giorgio Gandagliaa b c , Elisa De Lorenzisd, Giacomo Novarac, Nicola Fossatia b c, Ruben De Grootee, Zach Doveyc, Nazareno Suardia b, Francesco Montorsia b, Alberto Brigantia b, Bernardo Roccod and Alexandre Mottriec

European Urology, Volume 71 Issue 2, February 2017, Pages 249-256

Published online: 01 February 2017

Keywords: Prostate cancer, Radical prostatectomy, Extended pelvic lymph node dissection, Locally advanced, Robot assisted

Abstract Full Text Full Text PDF (1,9 MB)

Abstract

Background

Limited data are available on the role of robot-assisted radical prostatectomy (RARP) in patients with locally advanced prostate cancer (PCa).

Objective

To describe our surgical technique of extrafascial RARP and extended pelvic lymph node dissection (ePLND) in locally advanced PCa.

Design, setting, and participants

Ninety-four patients with clinical stage ≥T3 undergoing RARP with ePLND at three European centers between 2011 and 2015 were retrospectively evaluated.

Surgical procedure

Surgery was performed using the DaVinci Si system. The anatomically defined ePLND included nodes overlying the external iliac axis, those in the obturator fossa, and around the internal iliac artery up to the ureter. RARP was performed using an extrafascial approach where the Denonvillers’ fascia was dissected free and left on the posterior surface of the seminal vesicles.

Measurements

Perioperative outcomes consisted of operative time, blood loss, length of hospital stay, and complications occurred within 30 d after surgery. Biochemical recurrence (BCR) was defined as two consecutive prostate-specific antigen values ≥0.2 ng/ml. Kaplan-Meier analyses assessed time to BCR and clinical recurrence. Multivariable Cox regression analyses assessed predictors of BCR.

Results and limitations

Median operative time, blood loss, and length of hospital stay were 230 min, 200 ml, and 6 d. Overall, 12 (12.7%) patients experienced complications and five (5.3%), four (4.3%), and three (3.2%) patients had Clavien I, II, and III/IV complications. Overall, 72 (76.6%), 35 (37.2%), and 30 (32.3%) patients had pT3/4, pN1, and positive margins. The median number of nodes removed was 16. Overall, 19 (20.2%) and 21 (22.3%) patients received adjuvant radiotherapy and hormonal therapy. The median follow-up was 23.5 mo. At 3-yr follow-up, the BCR- and clinical recurrence-free survival rates were 63.3% and 95.8%. Pathologic stage, Gleason score, and positive margins represented predictors of BCR (all p ≤ 0.03). Our study is limited by its retrospective nature and by the follow-up duration.

Conclusions

RARP represents a well-standardized, safe, and oncological effective option in patients with locally advanced PCa. Pathologic stage, Gleason score, and positive margins should be considered to select patients for multimodal approaches.

Patient summary

Robot-assisted surgery represents a well-standardized, safe, and oncological effective option in men with locally advanced prostate cancer. Two out of three patients treated with this approach are free from recurrence at 3-yr follow-up. Pathologic stage, Gleason score, and positive surgical margins represent predictors of BCR and should be considered to select patients for multimodal approaches.

Take Home Message

We evaluated patients with locally advanced prostate cancer treated with robot-assisted radical prostatectomy and extended pelvic lymph node dissection. Our series demonstrates that this surgical approach is a safe and effective option in this setting, where only one out of 10 patients treated with robot-assisted radical prostatectomy experienced postoperative complications and two out of three patients were free from recurrence at the 3-yr follow-up.

Keywords: Prostate cancer, Radical prostatectomy, Extended pelvic lymph node dissection, Locally advanced, Robot assisted.

Footnotes

a Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy

b Department of Urology, Vita-Salute San Raffaele University, Milan, Italy

c OLV Vattikuti Robotic Surgery Institute, Melle, Belgium

d Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy

e Department of Urology, Onze-Lieve-Vrouw Hospital, Aalst, Belgium

Corresponding author. Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Via Olgettina 58, Milan 20132, Italy. Tel. +39 0226437286; Fax: +39 0226437286.

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