Comparison of outcomes of salvage robot-assisted laparoscopic prostatectomy for post-primary radiation vs focal therapy

Objectives: To compare salvage robot-assisted laparoscopic prostatectomy (RALP) outcomes in patients who underwent radiation and those who underwent focal ablation as primary therapies.

Patients and methods: We evaluated 126 patients who underwent salvage RALPbetween 2008 and 2018. Of these, 94 (74.6%) received radiation and 32 focal ablation (25.4%) as primary therapy. These groups were compared with regard to clinical, oncological and functional outcomes. Kaplan-Meier curves and regression models were used to identify survival estimations and their predictors.

Results: Before surgery, more patients were potent in the focal ablation group compared to the radiation group (46.9% vs 22.6%; P = 0.013). Peri-operative characteristics and complication rates were not significantly different between the two groups. Postoperative catheterization duration was shorter in the focal ablation group (mean 10 vs 16 days; P = 0.018). At final pathology, the focal ablation group had higher non-organ-confined disease (71% vs 50%; P = 0.042) and positive surgical margin (PSM) rates (43.8% vs 17%; P = 0.004) as compared to the radiation group; however, 5-year biochemical recurrence (BCR)-free survival rates were similar (59% vs 56%; P = 0.761). Postoperative 1-year full (no pads/day) and social (0-1 pad/day) continence rates were significantly higher in the focal ablation as compared to the radiation group (77.3% vs 39.2%, P = 0.002, and 87.5% vs 51.3%, P = 0.002, respectively). Multivariate analyses showed primary focal ablation and nerve-sparing to be predictors of postoperative continence. Erectile function was preserved in 13% and 27% of preoperatively potent patients in the radiation and focal ablation groups, respectively (P = 0.435). No predictors were identified for postoperative potency.

Conclusions: Radiation was associated with inferior functional outcomes after salvage RALP. Focal therapies were associated with higher non-organ-confined disease and PSMrates, with no significant difference in short-term BCR-free survival.