JCU - January 2022 - 26

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Journal of Clinical Urology 15(1)
Introduction
Despite the stage migration of prostate cancer (CaP) presentation1
almost one-third of patients present with high-risk
features.2 These patients are at considerable risk of recurrence
after treatment, often as a result of the presence of
occult metastases at the time of diagnosis.3-5 Much of the
literature in recent years has focussed on the role of radiotherapy
and androgen deprivation therapy (ADT) versus
surgery as part of a multimodal approach with further adjuvant
and salvage treatments directed to the prostate.6
Advocates of radiotherapy base their views on longstanding
randomised data demonstrating prolonged clinical
disease-free and overall survival (OS) in patients with
advanced prostate cancer after radiotherapy in combination
with ADT, compared with radiotherapy alone.7-9 In
addition, there have been concerns regarding the use of
surgery in the these patients due to apparent poor oncological
and functional outcomes.10
Opposing these views are supporters of surgery who use
outcome data from large surgical series demonstrating, at
the very least, equivalence to radiotherapy.11-14 Furthermore,
proponents of surgery discuss the large volume of retrospective
cohort data suggesting superiority for surgery versus
radiotherapy in terms of cancer-specific survival (CSS)
and OS.15-18
It is interesting to note the effect of these opposing
views. Epidemiological data demonstrate a shift in practice
at the turn of the century from increasing use of radiotherapy
and long-term ADT, to an increase in the use of
surgery.16,19 This shift has continued, with more recent data
demonstrating that approximately one-fifth of patients
with locally advanced CaP undergo surgery in the UK20
and two-thirds of European urologists would favour surgery
over radiotherapy in this high-risk setting.21
The aim of the present study was to define the outcomes
of a contemporary cohort of patients identified with pathological
T3a, T3b and N1 disease following treatment with
robotic radical prostatectomy in a high volume tertiary
centre. The focus of the paper is on immediate surgical
outcomes, postoperative functional outcomes, and also on
the details and success of subsequent salvage treatment
following biochemical failure.
Methods
Data were collected from our prospectively updated institutional
database, which was constructed in 2009, which is
automatically and manually updated in real time to include
information on surgical, functional and oncological outcomes.
All patients with high-risk and very high-risk CaP
according to the National Comprehensive Cancer Network
(NCCN) criteria22 are routinely offered surgery in our centre.
This is reflected in a pathological T3a, T3b or N1 rate
of approximately 70%, compared to a national average of
approximately 30% at the time of writing this paper.23
All patients with pathological high-risk disease, including
T3aN0, T3bN0 and/or any N1, were identified within
the database. Members of the pelvic oncology team performed
all surgical procedures, each of whom perform
approximately 100 robotic-assisted laparoscopic radical
prostatectomies (RALPs) per year. Patients identified preoperatively
with high-risk disease underwent an extended
lymph node dissection; clearance of the lymphatic tissue
along the major vessels below where the ureter crosses the
common iliac artery.24
Data were extracted on 669 patients. Information
included demographics, preoperative cancer parameters,
short and long-term complications, functional results, biochemical
recurrence (BCR), type and oncological outcome
of salvage treatments, CSS and OS.
Patients were reviewed regularly postoperatively with
prostate-specific antigen (PSA) blood tests and documentation
of all subsequent adjuvant and salvage treatments
after RALP, including the effects on BCR. BCR was
defined as any detectable PSA postoperatively, due to the
fact that many patients receive salvage treatments at PSA
levels below the standard definition of BCR (⩾0.3 ng/ml).
Precise details were collected on initial and all subsequent
salvage treatments including their success in terms of
BCR. Information included the duration and fractions of
radiotherapy, the duration and type of ADT, details of
chemotherapeutic and targeted therapy regimes.
Predictors of BCR and the effectiveness of salvage
treatments in terms of subsequent BCR were assessed with
a Kaplan-Meier method/log-rank test and with Cox regression
using EXCEL/WinSTAT (Microsoft).
Results
Patient age, preoperative PSA and postoperative pathology
are shown in Table 1. Of the 669 patients, the median age
was 65 years (range 44-78), the median diagnostic PSA
was 11 (range 1.2-118), median follow-up was 66 months
(range 8-129), 394 patients had pathological T3a disease
(58.9%), 250 patients pT3b (35.9%) and 76 patients
(11.4%) N1 disease. 487 patients had Gleason 7 cancer
(72.8%) and 100 patients had Gleason 8-10 (14.9%).
Details of the surgical outcomes and immediate and
delayed postoperative complications are shown in Table 2.
The median length of stay was one day (mean 1.82, range
1-17) and the transfusion rate was 0.6% (n=4). The overall
complication rate was 9.1% (n=61). Eleven patients (1.6%)
experienced 3 or greater Clavien-Dindo complications,
four developed a pelvic collection requiring percutaneous
drainage, two returned to theatre for a pelvic haemorrhage,
one returned to theatre for a port-site bleed, one patient
developed an anastamotic leak and required high-dependency
unit (HDU) admission, one developed an anastamotic
leak managed with a percutaneous drain, one patient
developed cholecystitis requiring HDU admission and one

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