Robotic salvage retroperitoneal and pelvic lymph node dissection for 'node-only' recurrent prostate cancer: technique and initial series

Comparative analysis of robot-assisted and open approach for PSMA-radioguided surgery in recurrent prostate cancer

PURPOSE

To compare the oncological and surgical outcomes of patients with recurrent prostate cancer (PCa) who underwent either open or newly established robot-assisted salvage prostate-specific membrane antigen-radioguided surgery (PSMA-RGS).

MATERIALS AND METHODS

Patients who consecutively underwent PSMA-RGS for PCa recurrence between January 2021 and December 2022 were identified. The rate of complete biochemical response, biochemical recurrence-free survival [BFS], and the rate of salvage therapy were evaluated. Univariable and multivariable regression models tested the association between the surgical approach and surgical outcomes.

RESULTS

Overall, 85 patients were selected, with 61 patients (72%) undergoing open PSMA-RGS and 24 patients (28%) receiving a robot-assisted approach. The oncological outcomes of the two groups were comparable (12-month BFS: 41% (Confidence interval (CI): 29-58%) vs. 39% (CI: 19-79%), p = 0.9, respectively). According to multivariable regression models, the robotic approach did not significantly influence estimated blood loss (EBL) (β = -40, 95% CI: -103, 22; p = 0.2) and significantly increased operative time (OT) (β = 28, 95% CI: 10, 46; p = 0.002). No Clavien-Dindo III-V complications were reported in the robotic group.

CONCLUSION

Both, the open as well as the robot-assisted approach for PSMA-RGS had comparable oncological outcomes. No safety concerns arose for the robotic-assisted approach offering a potentially improved quality of life for patients.

Salvage lymphadenectomy after primary therapy with curative intent for prostate cancer

PURPOSE OF REVIEW

To provide a summary of the current literature on salvage lymph node dissection (sLND) in patients with nodal recurrent prostate cancer (PCa) with focus on imaging, the extent of sLND and oncologic outcomes.

RECENT FINDINGS

The clinical practice guidelines recommend performing PET/CT in patients with biochemical recurrence (BCR) after primary therapy. PSMA PET/CT has demonstrated superiority over choline PET/CT and MRI, especially at low prostate-specific antigen (PSA) levels. Although the heterogeneity in available literature does not allow standardization of surgical templates for sLND and PET/CT scan can guide the extent of surgical dissection, an anatomically defined extended template is typically considered. Radio-guided surgery (RGS) suggests an improved positive lymph node yield compared with standard sLND. However, long-term data are needed to evaluate the oncologic impact of sLND. The main aims of sLND are to delay recurrence and to postpone the need for systemic therapy. Available evidence suggests that around 40-80% of men can achieve complete biochemical response after sLND and 10-30% remain BCR free after 5 years. Robotic sLND might represent an option to reduce the risk of complications without compromising oncological outcomes; validation in controlled prospective studies is, however, needed.

SUMMARY

sLND is a valid treatment option for patients with nodal recurrence only after primary therapy for PCa. Further optimization of patient selection based on highly sensitive and specific imaging and clinical factors remains an unmet need. To maximize the benefit of this approach, sLND should be discussed with patients who harbor lymph node-only recurrence after primary therapy in a shared decision-making.

68Ga-PSMA ligand PET/CT integrating indocyanine green-guided salvage lymph node dissection for lymph node metastasis after radical prostatectomy

To efficiently remove all recurrent lymph nodes (rLNs) and minimize complications, we developed a combination approach that consisted of 68Gallium prostate-specific membrane antigen (PSMA) ligand positron emission tomography (PET)/computed tomography (CT) and integrated indocyanine green (ICG)-guided salvage lymph node dissection (sLND) for rLNs after radical prostatectomy (RP). Nineteen patients were enrolled to receive such treatment. 68Ga-PSMA ligand PET/CT was used to identify rLNs, and 5 mg of ICG was injected into the space between the rectum and bladder before surgery. Fluorescent laparoscopy was used to perform sLND. While extensive LN dissection was performed at level I, another 5 mg of ICG was injected via the intravenous route to intensify the fluorescent signal, and laparoscopy was introduced to intensively target stained LNs along levels I and II, specifically around suspicious LNs, with 68Ga-PSMA ligand PET/CT. Next, both lateral peritonea were exposed longitudinally to facilitate the removal of fluorescently stained LNs at levels III and IV. In total, pathological analysis confirmed that 42 nodes were rLNs. Among 145 positive LNs stained with ICG, 24 suspicious LNs identified with 68Ga-PSMA ligand PET/CT were included. The sensitivity and specificity of 68Ga-PSMA ligand PET/CT for detecting rLNs were 42.9% and 96.6%, respectively. For ICG, the sensitivity was 92.8% and the specificity was 39.1%. At a median follow-up of 15 (interquartile range [IQR]: 6-31) months, 15 patients experienced complete biochemical remission (BR, prostate-specific antigen [PSA] <0.2 ng ml-1), and 4 patients had a decline in the PSA level, but it remained >0.2 ng ml-1. Therefore, 68Ga-PSMA ligand PET/CT integrating ICG-guided sLND provides efficient sLND with few complications for patients with rLNs after RP.

Robotic salvage pelvic lymph node dissection for locoregional recurrence after radical prostatectomy: a single institution experience

OBJECTIVES

To assess treatment response (PSA < 0.2 ng/ml), need for additional therapy and complication rate after robot assisted salvage pelvic lymph node dissection (sPLND).

MATERIAL AND METHODS

Analysis of outcomes data from radical prostatectomy (RP) patients consecutively operated with robot assisted sPLND due to biochemical recurrence and positron-emission tomography (PET)/computed tomography (CT)-detected nodal recurrence of pelvic lymph nodes.

RESULTS

Sixty-nine patients underwent robotic sPLND after a median time of 47 months post- RP. Sixty-four patients (93%) had malignant lymph nodes upon histological assessment of sPLND specimen. Twenty patients (29%) achieved PSA < 0.2 ng/ml 6 weeks postoperatively. After median (IQR) follow-up of 15 months (10-27), fourteen patients (20%) still had PSA < 0.2 ng/ml without additional therapy and forty-one patients (59%) had started additional therapy. No significant predictor for treatment response was found. Postoperative complications occurred in 14 patients (20%). Eleven of these complications were classified as Clavien-Dindo grade 1.

CONCLUSION

Oncological benefit of sPLND as the only salvage procedure seems to be limited, though almost one third of patients achieved treatment response. Clinical trials are needed to determine if sPLND as part of a multimodal treatment may improve outcome.

18F-choline positron emission tomography/computed tomography guided laparoscopic salvage lymph node dissection in patients after radical prostatectomy

Introduction

Salvage lymph node dissection (sLND) using novel imaging methods is an interesting alternative to treat lymph node (LN) metastasis after radical prostatectomy (RP); however, recommendations for using sLND as such are still being developed.

Aim

To assess the clinical outcomes of prostate cancer (PCa) after fluorine-18-choline (18F-choline) positron emission tomography/computed tomography (PET/CT) guided sLND.

Material and methods

Ten patients who had undergone sLND under 18F-choline PET/CT guidance (positive nodes: median 1, range 1-3) and had biochemical recurrence or persistence of prostate-specific antigen (PSA: median PSA 2.05 ng/ml, range: 0.8–8.4) after RP were enrolled in this retrospective study. Complete biochemical response (cBCR) after salvage surgery was defined as PSA < 0.2 ng/ml.

Results

The median follow-up time after salvage surgery was 33 months. The median PSA level 6 weeks after sLND and at the end of follow-up was 0.93 and 2.95 ng/ml, respectively. At 6 weeks after targeted sLND only 1 patient had cBCR, whereas a PSA decrease was noted in 7 patients. No patient had cBCR at the end of follow-up.

Conclusions

Laparoscopic sLND in cases of LN metastatic PCa after RP is a feasible option with low morbidity. However, an initial cBCR occurs in a negligible proportion of patients, and a long-term response is unlikely to be achieved.

Salvage Pelvic Lymph Node Dissection and Current State of Imaging for Recurrent Prostate Cancer: Does a Standard Exist?

PURPOSE OF REVIEW

We aim to evaluate the efficacy of salvage lymph node dissection (SLND) for nodal recurrent prostate cancer after primary treatment. We also provide a review of the diagnostic performance of next-generation sequencing (next-generation imaging (NGI)) radiotracers in the salvage setting.

RECENT FINDINGS

Most studies evaluating SLND include a heterogeneous population with a small sample size and are retrospective in design. The 5-year clinical recurrence-free and cancer-specific survival following SLND are 26-52% and 57-89%, respectively, among prospective studies. NGI improves accuracy in detecting nodal recurrence compared to conventional CT, with PMSA PET-CT showing the most promise. However, limited studies exist comparing imaging modalities and performance is variable at low PSA values. SLND is a promising treatment option, but more prospective data are needed to determine the ideal surgical candidate and long-term oncologic outcomes. More studies comparing different NGI are needed to determine the best imaging modality in patients who may be candidates for salvage treatment.

Role of salvage lymph node dissection in patients previously treated for prostate cancer: systematic review

Prostate cancer is the most common invasive cancer in men. Radical prostatectomy (RP) is a definitive treatment option, but biochemical recurrence can reach 40%. Salvage lymphadenectomy is a relatively recent approach to oligometasis and has been rapidly diffused primarily due to improvement in imaging diagnosis and results showing possibly promising therapy. A systematic literature review was performed in March 2020, according to the PRISMA statement. We excluded studies with patients with suspicion or confirmation of visceral and / or bone metastases. A total of 27 articles were included in the study. All studies evaluated were single arm, and there were no randomized studies in the literature. A total of 1,714 patients received salvage lymphadenectomy after previous treatment for localized prostate cancer. RP was the most used initial therapeutic approach, and relapses were based on PET / CT diagnosis, with Coline-11C being the most widely used radiopharmaceutical. Biochemical response rates ranged from 0% to 80%. The 5 years - Free Survival Biochemical recurrence was analyzed in 16 studies with rates of 0% up to 56.1%. The articles do not present high levels of evidence to draw strong conclusions. However, even if significant rates of biochemical recurrence are not evident in all studies, therapy directed to lymph node metastases may present good oncological results and postpone the onset of systemic therapy. The long-term impact in overall survival and quality of life, as well as the best strategies for case selection remains to be determined.

Robotic-assisted surgery for the treatment of urologic cancers: recent advances

INTRODUCTION

As the medical field is moving toward personalized and tailored approaches, we entered the era of precision surgery for the management of genitourinary cancers1. This is facilitated by the implementation of new technologies, among which robotic surgery stands out for the significant impact in the surgical field over the last two decades.

AREAS COVERED

This article reviews the latest evidence on robotic surgery for the treatment of urologic cancers, including prostate, kidney, bladder, testis, and penile cancer. Functional and oncologic outcomes, new surgical techniques, new imaging modalities, and new robotic platforms are discussed.

EXPERT OPINION

Robotic surgery had a growing role in the management of genitourinary cancers over the past 10 years. Despite a lack of high-quality evidence comparing the effectiveness of robotic to open surgery, the robotic approach allowed a larger adoption of a minimally invasive surgical approach, translating into lower surgical morbidity and shorter hospital stay. New robotic platforms might allow to explore novel surgical approaches, and new technologies might facilitate surgical navigation and intraoperative identification of anatomical structures, allowing a more tailored and precise surgery. It is an exciting time for robotic surgery, and upcoming technological advances will offer better outcomes to urologic cancer patients.

Comparison of Peri-operative and Early Oncological Outcomes of Robot-Assisted vs. Open Salvage Lymph Node Dissection in Recurrent Prostate Cancer

Introduction: Salvage lymph node dissection (sLND) has been proposed as a treatment option for prostate cancer patients with lymph node (LN) recurrence following radical prostatectomy to delay or avoid palliative androgen deprivation therapy (ADT). Historically sLND has been performed using an open approach, with its associated morbidity. A limited number of studies have reported peri-operative outcomes following robot-assisted sLND. However, a direct comparison with the open approach has hitherto not yet been reported. This study investigates whether robot-assisted sLND is associated with better peri-operative outcomes compared to the open approach. Early oncological outcomes are also compared. Patients and methods: In this retrospective study, clinical data were collected from 60 patients undergoing open sLND between 2010-2016 and 30 patients undergoing robot-assisted sLND between 2016 and 2018 at our tertiary referral center. The primary objective of the study was to compare peri-operative outcomes (length of stay, estimated blood loss, operative time, intra-operative, and postoperative complications) and LN yield between both procedures. As secondary objective early oncological outcome [biochemical recurrence-free survival (BRFS) and clinical recurrence-free survival (CRFS)] was compared. Variables of interest were compared using the chi-squared test (categorical variables), two sample t-test, and Mann-Whitney U-test (continuous variables). To compare BRFS and CRFS, Kaplan-Meier analysis, and log-rank tests were performed. Results: Robotic sLND was associated with reduced blood loss (median 100 vs. 275cc; p < 0.0001) and shorter length of stay (median 2 vs. 7 days; p < 0.0001) compared to open sLND. Moreover, postoperative complications within 30 days after surgery were more prevalent in the open sLND group compared to the robotic group (41.6% vs. 20%, p = 0.04). No significant differences in LN yield (for each sLND template), BRFS, and CRFS were detected between both groups. Conclusion: Robot-assisted sLND is associated with significantly reduced peri-operative morbidity compared to open sLND. No difference in LN yield, BRFS and CRFS was seen between both groups. Modern imaging techniques underestimate the tumor burden and therefore, the surgical sLND template should not be limited to the positive spots on pre-operative imaging.

[Oligometastatic prostate cancer management]

OBJECTIVE

To review biology and management of oligometastatic prostate cancer.

MATERIAL AND METHODS

Relevant publications were identified through Medline (www. ncbi.nlm.nih.gov), Embase (www.embase.com) and the US National Library of Medicine (www.clinicaltrials.org) databases using the following keywords, alone or in association, «prostate cancer; metastasis; oligo-metastasis». Articles were selected according to methods, language of publication and relevance. After careful selection 99 publications were eligible for our review.

RESULTS

Oligometastatic prostate cancer is a new entity including prostate cancer with a limited number of metastasis. This particular state becomes more frequent with the imaging progresses especially with the common use of new PET imaging with Choline or PSMA. There is no consensus about a strict definition of oligometastatic prostate cancer, number and sites of metastasis vary widely in the literature. Moreover, oligometastatic state can be observed de novo at the time of prostate cancer diagnosis as well as in case of recurrence after a primary treatment. There is actually an important lack of evidence-based medicine and no guidelines regarding treatment can be found. In de novo oligo-metatastatic prostate cancer, treatment of the primary tumor in association with androgen deprivation therapy seems to increase survival in selected patients but this needs to be confirmed by ongoing prospective clinical trials. In recurrent prostate cancer, metastasis directed therapy with or without androgen deprivation therapy is now routinely performed but its impact needs also to be analyzed.

CONCLUSION

In absence of consensus or guidelines, management of prostate cancer should be an individualized, patient-based management taking into account primary tumor stage and grade, number and types of metastasis and patient characteristics.

Salvage lymphadenectomy in recurrent prostate cancer: is there evidence of real benefit?

PURPOSE

Nodal recurrent prostate cancer (PCa) after primary radical treatment represents a heterogeneous entity with many treatment options. In some cases, surgical removal of metastatic nodes seems to improve cancer control and delay systemic treatments. The objectives of this study were to analyze the available literature on salvage lymphadenectomy for the treatment of nodal recurrent PCa and to elucidate the real oncological benefit deriving from this procedure.

METHODS

A PubMed search was performed using the following terms: prostate cancer, metastatic, oligometastatic, salvage lymphadenectomy, salvage lymph node dissection, salvage lymph node excision, and cytoreductive surgery. We included in the study all papers on salvage lymphadenectomy in nodal recurrent PCa, with no temporal limits. In addition, several papers addressing cytoreductive surgery and the biology of oligometastatic disease, published in different medical and basic research journals, were included.

RESULTS

Salvage lymphadenectomy is still characterized by a lack of standardization in patient selection and surgical template. Its primary objectives are to prolong progression-free survival and to delay the need for systemic therapy. The improvements in preoperative imaging techniques in conjunction with the wide use of minimally invasive surgery have generated growing interest in this procedure.

CONCLUSION

Salvage lymphadenectomy is a promising treatment approach; however, its real oncological benefit is still far from proven. Prospective randomized trials need to be designed to improve understanding of this issue.

Which Patients with Clinically Node-positive Prostate Cancer Should Be Considered for Radical Prostatectomy as Part of Multimodal Treatment? The Impact of Nodal Burden on Long-term Outcomes

BACKGROUND

A role for local therapies including radical prostatectomy (RP) in prostate cancer (PCa) patients with clinical lymphadenopathies has been proposed. However, no data are available to identify men who would benefit from RP in this setting.

OBJECTIVE

To identify predictors of clinical recurrence (CR) in surgically managed PCa patients with clinical lymphadenopathies.

DESIGN, SETTING, AND PARTICIPANTS

We identified 162 patients with lymphadenopathies treated with RP and lymph node dissection at three referral centers.

OUTCOME MEASURES AND STATISTICAL ANALYSES

CR was defined as the onset of metastases detected by conventional imaging. Kaplan-Maier analyses assessed time to CR after stratifying patients according to the site of lymphadenopathies and nodal burden. Regression tree analysis stratified patients into risk groups on the basis of their preoperative characteristics.

RESULTS AND LIMITATIONS

Overall, 80% of patients had lymphadenopathies in the pelvis alone and 20% in the retroperitoneum±pelvis. The median size of positive nodes was 13mm. A total of 84 patients (52%) received neoadjuvant androgen deprivation therapy and 127 (78%) had pathological lymph node invasion. The median follow-up for survivors was 64 mo. The 8-yr CR-free and CSM-free survival rates were 59% and 80%, respectively. Biopsy grade group and preoperative nodal burden should identify patients more likely to experience CR. While <10% of men with biopsy grade group 1-3 and two or fewer clinical lymphadenopathies developed CR, up to 60% of patients with biopsy grade group 4-5 and retroperitoneal node involvement ultimately experienced CR at 8 yr after RP. The discrimination of the regression tree was 76% according to the area under the receiver operating characteristic curve. Our study is limited by potential unmeasured confounders and the relatively small sample size.

CONCLUSIONS

Surgery in a multimodal setting might play a role in PCa patients with biopsy grade group 1-3 and/or enlarged nodes in the pelvis. Conversely, grade group 4-5 PCa and lymphadenopathies in the retroperitoneum are associated with worse oncologic outcomes.

PATIENT SUMMARY

Approximately half of prostate cancer patients with clinical lymphadenopathies treated with radical prostatectomy are free from metastases at 8-yr follow-up. Radical prostatectomy with or without systemic therapies might play a role in selected patients with biopsy grade group 1-3 disease and/or enlarged nodes in the pelvis. Conversely, a higher grade group and the presence of lymphadenopathies in the retroperitoneum should identify candidates for systemic therapies upfront.

Extended robotic salvage lymphadenectomy in patients with 'node-only' prostate cancer recurrence: initial experience

Introduction

Biochemical relapse (BR) after a primary radical prostatectomy may occur in up to 40 percent of cases. Salvage lymphadenectomy has been proposed in patients with ‘node-only’ driven BR, following a definitive treatment of primary prostate cancer (PCa). We present our initial series of 10 consecutive patients who underwent an extended robotic salvage pelvic lymph node dissection (eRSPLND) for ‘node-only’ recurrent PCa.

Materials and methods

It was a prospective study, including patients who presented with biochemical relapse after a primary radical prostatectomy at a median of 3.6 years prior. Clinical work-up that was done, including Magnetic resonance Imaging of chest/abdomen/pelvis and a bone scan, did not reveal any abnormalities. All patients underwent 11Choline PET (Positron Emission Tomography)/CT (Computed Tomography), which identified ‘node-only’ metastases.

Results

The median operative time was 73.4 mins, blood loss of 100 cc and hospital stay of 2 days. No patient had intra-operative complications, required an open conversion or any blood transfusion. Clavien II grade complications occurred in 1 patient (10%) and were managed conservatively. On histopathology, the median number of total and positive nodes per patient was 15 and 6, respectively. Overall, in our 10 patients, of the 157 total excised nodes, 38.8% were positive. Overall the median (range) PSA (prostate specific antigen) pre-operatively was 3.5 (1.6–3.7) ng/ml. At 3 months post-operatively, the median (range) PSA was 1.1 (0.2–3.4) ng/ml. This reflects an overall median PSA decrease of 31.4%. In no patient did the post-eRSPLND (extended Robotic Salvage pelvic lymphadenectomy) PSA reach zero.

Conclusions

eRSPLND allows the majority of patients to postpone hormonal treatment, which can theoretically decrease the cost of the treatment. 11Choline PET/CT identifies patients who are suitable for the eRSPLND. Longer follow-up is necessary to assess the oncologic outcomes.

[When is surgical treatment indicated in metastatic prostate cancer and what is the scientific rationale?]

BACKGROUND

Recent improvements in imaging diagnostics has led to a rising incidence of oligometastatic prostate cancer and, most notably, an increasing incidence of nodal-only biochemical recurrences. In this clinical setting, systemic therapy is still the treatment of choice. However, there is increasing evidence for surgical approaches in this challenging clinical setting.

AIM OF THE STUDY

In this comprehensive review article, current evidence regarding surgical approaches of primary nodal metastases, nodal-only biochemical recurrence following radical prostatectomy, and osseous metastatic prostate cancer will be discussed.

RESULTS

If nodal metastasis is clinically suspected, a significant survival benefit was observed in retrospective studies if radical prostatectomy and extended pelvic lymphadenectomy was performed within a multimodal therapeutic setting. Salvage lymphadenectomy as a therapeutic option for nodal-only biochemical recurrence is clinically feasible and can postpone systemic therapy significantly. However, since most patients do not have a lasting PSA response, a survival benefit of this therapeutic approach is questionable based on current evidence. Regarding osseous metastatic prostate cancer, the surgical approach has an inferior position compared to conservative management and radiotherapy.

CONCLUSION

Evidence regarding a surgical approach towards oligometastatic prostate cancer is increasing. However, current evidence is mainly based on retrospective studies that were conducted in the pre-PSMA-PET/CT era.