Salvage robotic prostatectomy for radio recurrent prostate cancer: technical challenges and outcome analysis

Morbidity of salvage radical prostatectomy: limited impact of the minimally invasive approach

PURPOSE

We aimed to report the morbidity profile of salvage radical prostatectomy (SRP) after radiotherapy failure and assess the impact of minimally invasive surgery (MIS) on postoperative complications and functional outcomes.

MATERIALS AND METHODS

Between 1985 and 2019, a total of 293 patients underwent SRP; 232 underwent open SRP; and 61 underwent laparoscopic SRP with or without robotic assistance. Complications were recorded and classified into standardized categories per the Clavien-Dindo classification.

RESULTS

Twenty-nine patients (10%) experienced grade 3 complications within 30 days, 22 (9.5%) after open and 7 (11%) after MIS (p = 0.6). Between 30 and 90 days after surgery, 7.3% of patients in the open group and 10% in the MIS group had grade 3 complications (p = 0.5). The most common complication was bladder neck contracture (BNC), representing 40% of the 30-90 day complications. Within one year of SRP, 81 patients (31%, 95% CI 25%, 37%) developed BNC; we saw non-significant lower rates in MIS (25 vs 32%; p = 0.4). Functional outcomes were poor after SRP and showed no difference between open and MIS groups for urinary continence (16 vs 18%, p = 0.7) and erectile function (7 vs 13%, p = 0.4). 5 year cancer-specific survival and overall survival was 95% and 88% for the entire cohort, respectively.

CONCLUSIONS

Our outcomes suggest poor functional recovery after SRP, regardless of the operative approach. Currently there is no evidence favoring the use of open or MIS approach. Further studies are required to ensure comparable outcomes between these approaches.

The SAFE Pilot Trial—SAlvage Focal Irreversible Electroporation—For Recurrent Localized Prostate Cancer: Rationale and Study Protocol

Introduction

Currently, the majority of prostate cancer (PCa) recurrences after non-surgical first-line treatment are managed with androgen-deprivation therapy (ADT). Salvage radical prostatectomy (sRP) is a curative alternative to ADT but yields significant morbidity. Preliminary evidence from focal salvage treatments shows similar oncological control but lower morbidity compared to sRP. Among available ablative focal energies, irreversible electroporation (IRE) is a treatment modality that proved promising, especially in treating apical lesions, where PCa most often recurs. Our aim is to test the safety of salvage IRE for recurrent PCa.

Methods

We performed a single-arm pilot feasibility study (IDEAL stage 2a): SAFE, SAlvage Focal irreversible Electroporation for recurrent localized PCa. Twenty patients with biopsy-proven PCa recurrence after primary non-surgical (radiation or ablation) treatment were included. All men will undergo mpMRI ± targeted biopsies, pre-operative PSMA-PET staging before inclusion and sIRE. Outcomes will be evaluated through internationally validated questionnaires and morbidity scales. All men will undergo a control biopsy at one year.

Results

Primary objectives were the evaluation of the safety of sIRE (and patients’ quality of life) after treatment. Secondary objectives were the evaluation of functional outcomes, namely, continence and erectile function changes and evaluation of short-term oncological efficacy.

Conclusions

SAFE is the second pilot study to evaluate sIRE and the first one performed according to the most recent diagnostic and staging imaging standards. sIRE may provide a curative option for recurrent PCa together with lower comorbidities compared to sRP.

Reirradiation for isolated local recurrence of prostate cancer: Mono-institutional series of 64 patients treated with salvage stereotactic body radiotherapy (SBRT)

OBJECTIVE:

To evaluate high-precision external beam reirradiation (re-EBRT) for local relapse of prostate cancer (PCa) after radiotherapy.

METHODS:

This retrospective study included patients with biochemical failure and evidence of isolated local recurrence of PCa after radical/salvage EBRT or brachytherapy that received salvage stereotactic body radiation therapy (SBRT, re-EBRT). Biopsy was not mandatory if all diagnostic elements were univocal (prostate specific antigen evolution, choline-positron emission tomography or magnetic resonance imaging). Salvage SBRT (re-EBRT) was delivered with image-guided radiation therapy (RapidArc®, VERO® and CyberKnife®).

RESULTS:

Data of 64 patients were included, median age at salvage SBRT was 73.2 years, median pre-salvage SBRT prostate specific antigen was 3.89  ng ml-1 . Median total dose was 30  Gy in five fractions, biologically effective dose (BED) of 150  Gy. One acute G3 genitourinary event and one late G3 genitourinary event were observed. No G ≥ 3 bowel toxicity was registered. At the median follow-up of 26.1 months, tumor progression was observed in 41 patients (64%). 18 patients (28%) experienced local relapse. 2-year local control, biochemical and clinical relapse free survival rates were 75, 40 and 53%, respectively. With BED ≥130  Gy 1-year biochemical and clinical progression-free survival rate were 85 and 90%, respectively.

CONCLUSIONS:

Salvage SBRT (re-EBRT) for isolated local PCa recurrence is a safe, feasible and noninvasive salvage treatment. Further investigation is warranted to define the optimal patient selection, dose and volume parameters.

ADVANCES IN KNOWLEDGE:

Salvage SBRT reirradiation for the locally recurrent PCa offer a satisfactory tumor control and excellent toxicity profile, if BED ≥130 Gy is administered.

Salvage high-intensity focused ultrasound versus salvage radical prostatectomy for radiation-recurrent prostate cancer: a comparative study of oncological, functional, and toxicity outcomes

PURPOSE

To compare oncological, functional, and toxicity outcomes of patients with radiation-recurrent prostate cancer (PCa) after external beam radiation therapy (EBRT) or brachytherapy (BT) treated with salvage high-intensity focused ultrasound (S-HIFU) or salvage radical prostatectomy (S-RP).

METHODS

This retrospective study compared 52 patients with radiation-recurrent PCa after EBRT or BT treated with S-HIFU (n = 27) or S-RP (n = 25) between 1998 and 2016. We estimated overall survival (OS), cancer-specific survival (CSS), and metastasis-free survival (MFS) at 5 years. Incontinence after local salvage therapy (LST) was scored according to the number of pads used per day. Complications were graded according to the Clavien-Dindo classification.

RESULTS

Both groups were similar for pre-LST tumor features, however, no S-HIFU patients received BT and S-RP patients were younger and healthier. Median follow-up was 45 months for S-HIFU and 43 months for S-RP. No significant differences were found in estimated 5-year OS (80.9% vs. 61.9%, p = 0.24), 5-year CSS (84.0% vs. 74.0%, p = 0.36), and 5-year MFS (60.3% vs. 55.2%, p = 0.55) for S-HIFU vs. S-RP, respectively. We observed a significant difference in pad-dependent status at 12 months (22.2% vs. 56.0%, p = 0.01) and in the number of Clavien ≥ III complications [9 (7/27 patients) vs. 16 (12/25 patients), p = 0.027] in favor of S-HIFU vs. S-RP, respectively.

CONCLUSION

S-HIFU and S-RP could both be considered valuable LST options for patients with radiation-recurrent nonmetastatic PCa with sufficient life expectancy. S-RP is associated with more pad-dependent patients at 12 months.

Expanding the indications of robotic surgery in urology: A systematic review of the literature

Objectives

To evaluate the recent developments in robotic urological surgery, as the introduction of robotic technology has overcome many of the difficulties of pure laparoscopic surgery enabling surgeons to perform complex minimally invasive procedures with a shorter learning curve. Robot-assisted surgery (RAS) is now offered as the standard for various surgical procedures across multiple specialities.

Methods

A systematic search of MEDLINE, PubMed and EMBASE databases was performed to identify studies evaluating robot-assisted simple prostatectomy, salvage radical prostatectomy, surgery for urolithiasis, distal ureteric reconstruction, retroperitoneal lymph node dissection, augmentation ileocystoplasty, and artificial urinary sphincter insertion. Article titles, abstracts, and full text manuscripts were screened to identify relevant studies, which then underwent data extraction and analysis.

Results

In all, 72 studies evaluating the above techniques were identified. Almost all studies were retrospective single-arm case series. RAS appears to be associated with reduced morbidity, less blood loss, reduced length of stay, and comparable clinical outcomes in comparison to the corresponding open procedures, whilst having a shorter operative duration and learning curve compared to the equivalent laparoscopic techniques.

Conclusion

Emerging data demonstrate that the breadth and complexity of urological procedures performed using the da Vinci® platform (Intuitive Surgical Inc., Sunnyvale, CA, USA) is continually expanding. There is a gaining consensus that RAS is producing promising surgical results in a wide range of procedures. A major limitation of the current literature is the sparsity of comparative trials evaluating these procedures.

IGF-1R associates with adverse outcomes after radical radiotherapy for prostate cancer

BACKGROUND

Activated type 1 insulin-like growth factor receptors (IGF-1Rs) undergo internalisation and nuclear translocation, promoting cell survival. We previously reported that IGF-1R inhibition delays DNA damage repair, sensitising prostate cancer cells to ionising radiation. Here we tested the clinical relevance of these findings.

METHODS

We assessed associations between IGF-1R and clinical outcomes by immunohistochemistry in diagnostic biopsies of 136 men treated with 55-70 Gy external beam radiotherapy for prostate cancer, comparing results with publicly available transcriptional data in surgically treated patients.

RESULTS

Following radiotherapy, overall recurrence-free survival was shorter in patients whose tumours contained high total, cytoplasmic and internalised (nuclear/cytoplasmic) IGF-1R. High total IGF-1R associated with high primary Gleason grade and risk of metastasis, and cytoplasmic and internalised IGF-1R with biochemical recurrence, which includes patients experiencing local recurrence within the radiation field indicating radioresistance. In multivariate analysis, cytoplasmic, internalised and total IGF-1R were independently associated with risk of overall recurrence, and cytoplasmic IGF-1R was an independent predictor of biochemical recurrence post radiotherapy. Insulin-like growth factor receptors expression did not associate with biochemical recurrence after radical prostatectomy.

CONCLUSIONS

These data reveal increased risk of post-radiotherapy recurrence in men whose prostate cancers contain high levels of total or cytoplasmic IGF-1R.