Three-year biochemical recurrence after Retzius-sparing RALP

Back in January this year we commented on a technique known as Retzius-sparing radical prostatectomy, which — according to its advocates — is said to facilitate recovery of erectile function post-surgery. However, we also noted that, as with many other new surgical techniques, it takes time to learn to do well.

One of the initial developers of this technique is Dr. Koon Ho Rha of the Yonsei University College of Medicine in Seoul, Korea. In a recently published paper, Dr. Rha and colleagues (see here) have just reported data on a cohort of 359 consecutive, non-metastatic patients with prostate cancer — all treated by Retzius-sparing, robot-assisted laparoscopic radical prostatectomy (RALP) between November 2012 and November 2016 — with specific reference to their risk for biochemical recurrence.

Based on the National Comprehensive Cancer Network prostate cancer risk classification, the authors state that:

  • 164/359 patients (45.7 percent) had high‐ or very high‐risk prostate cancer.
  • No patient received any form of adjuvant therapy until biochemical recurrence could be formally documented.

At an average (median) follow-up of 26 months (i.e., just over 2 years)

  • The overall biochemical recurrence rate was 14.8 percent.
  • Average (median) time to biochemical recurrence was 11 months.
  • The actuarial probability of biochemical recurrence‐free survival at 3 years was
    • 71.2 percent for very high-risk patients
    • 72.1 percent for high-risk patients
    • 88.7 percent for intermediate-risk patients
    • 82.3 percent for low-risk patients
    • 95.7 percent for very low‐risk patients
  • On multivariable analysis,the following markers were all statistically significant indicators of risk for biochemical recurrence:
    • Preoperative PSA level (hazard ratio [HR] = 1.03)
    • Percentage of maximum core involvement on biopsy (HR = 1.02)
    • Clinical stage ≥ T3a (HR = 2.12)
  • The following two measures were the key (and statistically significant) pathological and postoperative predictors of biochemical recurrence:
    • Pathological Gleason score ≥ 8 (HR = 5.63)
    • Pathological tumor volume (HR =1.08)

The authors conclude that:

Retzius‐sparing robot‐assisted radical prostatectomy confers effective biochemical recurrence control at the mid‐term follow‐up period. Preoperative prostate‐specific antigen, advanced clinical stage and higher Gleason score were important predictors of biochemical recurrence after Retzius‐sparing robot‐assisted radical prostatectomy. Long‐term oncological safety still needs to be established.

Clearly there is a way to go before we will have enough data to tell us whether Retzius-sparing RALP offers a new standard in surgical technique for the treatment of localized prostate cancer. However, we note that nearly half of the patients in this cohort had high or very high-risk prostate cancer at time of diagnosis and still had 3-year biochemical recurrence rates of > 70 percent. If these patients also had good rates of recovery of erectile function post-surgery, then the Retzius-sparing technique woulds appear to hold promise for the treatment of men with clinically significant disease who wish to be treated with first-line surgery.

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