Salvage robotic-assisted radical prostatectomy (sRARP) for local prostate cancer (PCa) recurrence after high-intensity focused ultrasound partial ablation (HIFU-PA) is relatively safe and provides acceptable continence, but oncologic outcomes and sexual function are poor, according to investigators.
In a study of 45 patients who underwent HIFU-PA(median age 63 years; PSA 7.2 ng/mL; 88.9% cT2) who underwent sRARP at a single center, median operative time was 140 minutes, blood loss was 200 mL, and hospital stay was 1 day. Clavien-Dindo grade 1, 2, and 3 complications occurred in 8.9%, 6.7%, and 2.2% of patients within 90 days. Of the 45 patients, only 33 had reached the 12-month follow-up point. Of these, 5 (15.2%) experienced a late complication such as bladder neck contracture during the 90 day to 12-month follow-up period, a rate higher than expected.
Substantial upgrading and upstaging occurred at sRARP pathology. Grade group 3 to 5 disease was observed in 51.1%, pT3a/b in 64.5%, and positive surgical margins in 44.4% (including 37.5% of those with pT2 and 48.3% of those with pT3), James E. Thompson, MBBS, PhD, of the University College London Hospital in London, and colleaguesreported in BMC Urology.
Adjuvant radiation (RT) or androgen deprivation therapy (ADT) was administered to 26.3% of men for residual disease or adverse pathologic features and to 5.3% of men for biochemical recurrence. Most recurrences were within the ablation zone and apical/anterior. Two-thirds of patients were free from ADT/RT at 12 months.
In regard to urinary incontinence, pad-free rates dropped from 95.3% post-HIFU to 65.5% at 12 months post-sRARP. No one retained sexual function after surgery, with potency rates falling from 65.5% post-HIFU to 0% at 12 months post-sRARP. Median International Index of Erectile Function-5 scores pre-HIFU, post-HIFU, and at 3- and 12-months post-sRARP declined from 23.5% to 16% to 5% and 5%, respectively. Bilateral and unilateral nerve sparing were feasible in just 7% and 22% of patients, respectively, Dr Thompson’s team noted.
Compared with data on primary RARP, erectile recovery, continence recovery, cancer recurrence, and anastomotic stricture rates appeared worse after sRARP, according to the investigators.
“HIFU-PA is an attractive choice to avoid the morbidity of radical treatment, but patients and their clinicians should consider the sub-optimal outcomes of sRARP when making initial and salvage treatment choices,” the authors concluded.
Thompson JE, Sridhar AN, Shaw G, et al. Peri-operative, functional and early oncologic outcomes of salvage robotic-assisted radical prostatectomy after high-intensity focused ultrasound partial ablation [published online July 1, 2020]. BMC Urol. 20:81. doi: 10.1186/s12894-020-00656-9