AdventHealth Orlando, Orlando, USA.
SUNY Upstate Medical University, Syracuse, NY, 13502, USA.
J Robot Surg. 2023 Dec;17(6):2995-3003. doi: 10.1007/s11701-023-01738-0. Epub 2023 Oct 30.
In the present study, we present comparative outcomes of radical prostatectomy after whole-gland therapy (wg-SRARP) and focal gland therapy (f-SRARP). The study assessed 339 patients who underwent salvage robot-assisted radical prostatectomy (SRARP); 145 patients who had primary focal therapy and 194 patients who had primary whole-gland treatment. SRARP was performed in all cases using a standardized technique developed at respective institutes with the da Vinci Xi Surgical System. Our primary endpoint was the comparison of the functional and oncological outcomes between the groups. Cox proportional hazard was used to study the functional and oncological outcomes. The median total operative time for f-SRARP was 18 min higher than wg-RARP (p < 0.001). Higher rates of nerve-sparing were performed in f-SRARP (focal vs whole gland; bilateral-15.2% vs 9.3%; unilateral 49% vs 28.4%; p < 0.001). wg-SRARP had higher rates of ISUP 5 (26.3% vs 19.3%; p < 0.001) and deferred ISUP score due to altered pathology (14.8% vs 0.7; p < 0.001), while f-SRARP had higher rates of ISUP 4 (11.7% vs 10.7%; p < 0.001) and ≥ pT3a (64.8% vs 51.6%; p < 0.001). Positive margins were significantly higher with f-SRARP (26.2% vs 10.3%; p < 0.001). Functional outcomes were poor in both the groups. However, postoperative continence was higher and faster in patients who had f-SRARP compared to wg-SRARP (69% vs. 54.6%; p = 0.013). We could not identify statistically significant difference in postoperative potency recovery and biochemical recurrence. We present the largest multi-institutional analyses of f-SRARP and wg-SRARP. SRARP is challenging wherein patients have adverse pathological features and increased surgical complexity irrespective of the primary treatment. Focal therapy group had higher rates of nerve-sparing, however, with increased positive surgical margins. Both groups had poor functional outcomes regardless of nerve-sparing degree, indicating significant ipsilateral and contralateral damage to tissues surrounding the prostate during primary treatment. We believe that this analysis is crucial for counseling patients regarding expected outcomes before performing a salvage treatment following ablative therapy failure.
在本研究中，我们比较了全腺体治疗后根治性前列腺切除术（wg-SRARP）和局灶性腺体治疗（f-SRARP）的结果。研究评估了 339 例接受挽救性机器人辅助根治性前列腺切除术（SRARP）的患者；145 例患者接受了原发性局灶治疗，194 例患者接受了原发性全腺体治疗。所有病例均采用各自研究所开发的标准化技术，使用达芬奇 Xi 手术系统进行 SRARP。我们的主要终点是比较两组的功能和肿瘤学结果。Cox 比例风险用于研究功能和肿瘤学结果。f-SRARP 的总手术时间中位数比 wg-RARP 长 18 分钟（p<0.001）。f-SRARP 中进行了更高比例的神经保留（局灶性 vs 全腺体；双侧-15.2% vs 9.3%；单侧 49% vs 28.4%；p<0.001）。wg-SRARP 的 ISUP5 更高（26.3% vs 19.3%；p<0.001），由于改变的病理学导致推迟的 ISUP 评分更高（14.8% vs 0.7%；p<0.001），而 f-SRARP 的 ISUP4 更高（11.7% vs 10.7%；p<0.001）和≥pT3a 更高（64.8% vs 51.6%；p<0.001）。f-SRARP 的阳性切缘显著更高（26.2% vs 10.3%；p<0.001）。两组的功能结果均较差。然而，与 wg-SRARP 相比，f-SRARP 的术后控尿率更高且更快（69% vs. 54.6%；p=0.013）。我们没有发现术后勃起功能恢复和生化复发方面有统计学意义的差异。我们报告了 f-SRARP 和 wg-SRARP 的最大多机构分析。SRARP 具有挑战性，因为患者具有不良的病理特征和增加的手术复杂性，而与原发性治疗无关。局灶性治疗组有更高的神经保留率，但是，阳性手术切缘增加。两组的功能结果均较差，无论神经保留程度如何，这表明在原发性治疗期间，前列腺周围组织发生了显著的同侧和对侧损伤。我们认为，在消融治疗失败后进行挽救性治疗之前，这种分析对于向患者提供预期结果的咨询非常重要。
