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Robot Assisted Radical Prostatectomy in Men with High Risk Prostate Cancer- Perioperative and Oncologic Outcomes
Ryan P. Dorin, M.D., Ilene Staff, Ph.D., Joe Tortora, MS, Stuart S. Kesler, M.D., Joseph R. Wagner, M.D..
Hartford Hospital, Hartford, CT, USA.

BACKGROUND: Robotic prostatectomy with pelvic lymph node dissection (RARP) is an increasingly utilized modality for primary therapy of patients with high risk prostate cancer. We sought to determine 5 year oncologic outcomes of patients treated with RARP for high risk prostate cancer.
METHODS: We reviewed our institutional IRB approved prostatectomy database for patients who underwent RARP as initial therapy for D’Amico high risk prostate cancer between 4/2003 and 12/2011. Patients were excluded if they had undergone previous prostate radiotherapy (RT) or neoadjuvant androgen deprivation therapy (ADT). Biochemical recurrence was defined as a PSA of ≥0.2, verified by a consecutive increase, or an elevated PSA prompting salvage therapy. Wilcoxon ranked sum test, chi-squared test of proportion, and student’s t-test were used for statistical comparisons. Kaplan-Meier (KM) curves were constructed to estimate biochemical recurrence free survival (bRFS). Complications were prospectively recorded and scored using the 2004 Clavien system.
RESULTS: 292 patients met inclusion criteria, with a median age of 62. 31 (11%) patients had a preoperative PSA of ≥20ng/dL, 64 (22%) patients were ≥cT2c, and 223 (76%) patients had biopsy Gleason sum ≥8. The mean follow-up interval was 29 months (range 8-105 months). There were 7 deaths, including one due to prostate cancer. 56% of patients had ≥pT3aN0 tumors, and 6.5% had LN involvement. There were 98 patients (33.6%) with a positive surgical margin. There were 32 early (<90 days) postoperative complications in 29 patients, including 7 Clavien ≥3a complications. There were 7 intraoperative complications, including 3 rectal injuries.
15 (5.1%) patients received adjuvant therapies (7 RT, 2 ADT, and 6 combination). 61 (21%) patients underwent salvage therapies at a mean interval from surgery of 15 months. The estimated 5 year bRFS rate was 61%, with a mean bRFS of 59 months (95% CI: 54-64 months). On univariate analyses, significant predictors of decreased bRFS were stage ≥pT3b (p<0.01), pathologic Gleason sum ≥8 (p<0.01), and clinical stage ≥cT1c (p<0.01). Margin status, biopsy Gleason sum, preop PSA ≥20, and clinical stage ≥cT2c were not significant predictors of bRFS. On multivariate analyses, pathologic Gleason sum ≥8 and pathologic tumor stage ≥pT3b remained predictive.
CONCLUSIONS: RARP resulted in significant long term disease free survival and low cancer specific mortality rates in patients with high risk prostate cancer. Complication rates were relatively low. Surgery should be considered in high risk patients who are good operative candidates.


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