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.
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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.
Reference
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
