Platinum Priority – Review – Prostate Cancer
Editorial by Francesco Montorsi on pp. 928–930 of this issue

The Role of Robot-assisted Radical Prostatectomy and Pelvic Lymph Node Dissection in the Management of High-risk Prostate Cancer: A Systematic Review eulogo1

By: Bertram Yuh a lowast , Walter Artibani b , Axel Heidenreich c , Simon Kimm d , Mani Menon e , Giacomo Novara f , Ashutosh Tewari g , Karim Touijer d , Timothy Wilson a , Kevin C. Zorn h and Scott E. Eggener i

European Urology, Volume 65 Issue 5, May 2014, Pages 918-927

Published online: 01 May 2014

Keywords: Prostate cancer, Prostatectomy, High risk, Robotic, Lymph node dissection

Abstract Full Text Full Text PDF (1,0 MB)



The role of robot-assisted radical prostatectomy (RARP) for men with high-risk (HR) prostate cancer (PCa) has not been well studied.


To evaluate the indications for surgical treatment, technical aspects such as nerve sparing (NS) and lymph node dissection (LND), and perioperative outcomes of men with HR PCa treated with RARP.

Evidence acquisition

A systematic expert review of the literature was performed in October 2012, searching the Medline, Web of Science, and Scopus databases. Studies with a precise HR definition, robotic focus, and reporting of perioperative and pathologic outcomes were included.

Evidence synthesis

A total of 12 papers (1360 patients) evaluating RARP in HR PCa were retrieved. Most studies (67%) used the D’Amico classification for defining HR. Biopsy Gleason grade 8–10 was the most frequent HR identifier (61%). Length of follow-up ranged from 9.7 to 37.7 mo. Incidence of NS varied, although when performed did not appear to compromise oncologic outcomes. Extended LND (ELND) revealed positive nodes in up to a third of patients. The rate of symptomatic lymphocele after ELND was 3%. Overall mean operative time was 168 min, estimated blood loss was 189 ml, length of hospital stay was 3.2 d, and catheterization time was 7.8 d. The 12-mo continence rates using a no-pad definition ranged from 51% to 95% with potency recovery ranging from 52% to 60%. The rate of organ-confined disease was 35%, and the positive margin rate was 35%. Three-year biochemical recurrence–free survival ranged from 45% to 86%.


Although the use of RARP for HR PCa has been relatively limited, it appears safe and effective for select patients. Short-term results are similar to the literature on open radical prostatectomy. Variability exists for NS and the template of LND, although ELND improves staging and removes a higher number of metastatic nodes. Further study is required to assess long-term outcomes.

Take Home Message

Robotic prostatectomy appears to be safe and effective for selected high-risk prostate cancer patients. Short-term results are similar to open radical prostatectomy. Extended node dissection improves staging and removes a higher number of metastatic nodes. Further follow-up is required to assess long-term outcomes.

Keywords: Prostate cancer, Prostatectomy, High risk, Robotic, Lymph node dissection.

1. Introduction

Prostate cancer (PCa), the most prevalent male malignancy in the United States, was diagnosed in approximately 240 000 men in 2012, and it represents the second most common cause of cancer-related death in the United States and Europe [1] . Despite prostate-specific antigen (PSA)-based screening and early detection guidelines, approximately 15–26% of PCa patients still present with high-risk (HR) features indicative of a more advanced and potentially lethal course [2] . HR characteristics are not only associated with biochemical recurrence but also with increased rates of secondary therapy, metastasis, and death [3] and [4].

Challenges exist in treating men with HR disease. The biologic behavior of HR cancer varies, and current diagnostic tools lack staging accuracy. Definitions of HR differ considerably, making prognostic assessment and outcome comparisons between treatments challenging [5] . Even for objective parameters such as Gleason score, grade migration can lead to time-dependent variance in risk groups [6] . Significant differences can exist within specific risk groups because patients may have anywhere from one to three HR features yet be classified similarly [7] .

Surgery and radiation are commonly offered to men with clinically localized PCa. Active surveillance leads to excellent long-term oncologic outcomes in low-risk patients, but HR patients appear to have the most to gain from definitive therapy [8] . Recent analyses advocating radical prostatectomy (RP) for men with HR cancer have demonstrated durable oncologic outcomes [9] . Nearly 40% of HR patients have organ-confined (OC) disease at RP, and these men experience excellent long-term survival while avoiding exposure to long-term androgen-deprivation therapy (ADT) [10] . Depending on the HR definition used, Yossepowitch et al. found OC cancers in 22–63% of patients undergoing RP with 72–98% metastasis-free survival 10 yr after surgery [4] . Despite the higher likelihood of biochemical recurrence and secondary therapy, HR patients have 10-yr cancer-specific survival (CSS) estimates after RP of approximately 90% [11] . European Association of Urology (EAU) guidelines now support a role for RP in select HR patients as a treatment option that may include a multimodality approach [12] .

Although RP is an important therapeutic option for select patients with HR PCa, the role of robot-assisted radical prostatectomy (RARP) has not been well investigated. No large series of RARP in HR patients or randomized trials comparing RARP with other treatments have been reported. In the past decade, RARP has been rapidly adopted into clinical practice, although only recently have outcomes specifically evaluated HR disease. Recent reviews comparing RARP with open RP have demonstrated similar positive surgical margin and biochemical recurrence rates with reduced blood loss and need for blood transfusion [13] as well as potential benefits to continence and erectile function recovery [14] . This review evaluates the indications, technical aspects, and short-term outcomes of RARP for men with HR clinically localized PCa.

2. Evidence acquisition

A systematic literature search of the Medline, Web of Science, and Scopus databases was performed in October 2012 using medical subject headings and free-text protocol. The search was restricted to the terms radical prostatectomy and lymph node dissection and publications written in the English language. In addition, the following limits were selected: male humans, cancer, and publications from January 1, 2000, to the present. American Urologic Association (AUA) and EAU abstracts were also reviewed, although they were excluded from the analysis. Review articles, abstracts, small case series, and publications not reporting categorical data for HR patients were excluded. Any additional studies cited in the references of the search papers were further reviewed.

Eligibility criteria for study inclusion consisted of (1) RARP surgical technique, (2) HR definition as well as selection of patients based on high PSA, Gleason grade 8–10, advanced clinical stage, or other HR criteria, and (3) reporting of perioperative and pathologic outcomes stratified for HR patients. Articles selected were reviewed and approved by all authors. Studies reporting outcomes based on clinical versus pathologic selection of HR patients were analyzed separately. Data extracted from the selected studies were entered into an electronic database. Complications were assessed according to established Martin criteria [15] and potency evaluation by the Mulhall criteria [16] . OC disease was defined as pathologic T2N0 disease on final specimen evaluation after RP. Descriptive statistics were used to summarize the clinical and pathologic data. Weighted averages were calculated because the number of patients varied across studies. The level of evidence for all studies was level 4 as described by the 2011 Oxford criteria [17] .

3. Evidence synthesis

Figure 1 depicts the systematic electronic search method. The search returned a total of 16 studies reporting RARP in HR PCa, 12 of which identified patients based on clinical criteria [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], and [29].


Fig. 1 Systematic electronic search method.

3.1. Definitions of high risk in robot-assisted radical prostatectomy series

Table 1 shows 12 RARP publications, all reported between 2008 and 2013, using a clinical definition of HR PCa. Of these, eight (67%) classified patients as HR using the D’Amico criteria (PSA >20 ng/ml, Gleason sum 8–10, clinical stage ≥T2c), and one study each by PSA, clinical stage, Gleason grade, and National Comprehensive Cancer Network (NCCN) (PSA >20 ng/ml, Gleason sum 8–10, clinical stage ≥T3) criteria alone. For the analyses by D’Amico criteria, 61% of patients met HR benchmarks by Gleason 8–10, which was significantly more common than clinical stage ≥T2c (10–36%) or PSA >20 ng/ml (16–23%).

Table 1 Summary of high-risk robot-assisted radical prostatectomy series by clinical criteria

Study Cases, n High-risk criteria PSA >20, n (%) PSA, ng/ml, median/mean ≥cT2c, n (%) cT3, n (%) Gleason 8–10, n (%)
Shikanov et al. [18] 70 Gleason 8–10 8.36 4 (6) 0 70 (100)
Ham et al. [19] 121 ≥cT3a 65.8 121 (100) 121 (100) 59 (49)
Zugor et al. [20] 147 PSA >20 147 (100) 34.8
Connolly et al. [21] 160 NCCN 48 (30) 9.9 38 (24) 32 (20) 120 (75)
Yee et al. [22] 62 D’Amico 6.9 19 (31) 46 (74)
Lavery et al. [23] 123 D’Amico 21 (17) 10.8 12 (10) 5 (4) 99 (81)
Rogers et al. [24] 69 D’Amico 11 (16) 7.2 25 (36) 12 (17) 43 (62)
Jayram et al. [25] 148 D’Amico 11.3 112 (76)
Sagalovich et al. [26] 82 D’Amico 7.4 76 (93)
Yuh et al. [27] 30 D’Amico 7 (23) 10.1 4 (13) 1 (3) 22 (73)
Ou et al. [28] 148 D’Amico 20.8 18 (13) 44 (30)
Jung et al. [29] 200 D’Amico Group 1: 8.7

Group 2: 15.5
119 (60) 80 (40)

NCCN = National Comprehensive Cancer Network; PSA = prostate-specific antigen.

All studies were level 4 evidence.

A total of 1360 patients (range per study: 30–200) were examined. Length of follow-up after RARP ranged from 9.7 to 37.7 mo. Neoadjuvant ADT was administered in <5% of patients. Presenting clinical characteristics varied among studies even within the same selection criteria. For instance, median PSA was 12 ng/ml (range: 6.9–20.8 ng/ml) for the D’Amico selected studies but 65.8 ng/ml in a study of clinical T3 tumors [19] . Three studies reported percentage of positive biopsy cores ranging from 33% to 37%.

3.2. Technique of robot-assisted radical prostatectomy in high-risk prostate cancer

3.2.1. Nerve-sparing robot-assisted radical prostatectomy for high-risk prostate cancer

In the retrieved publications, NS was highly variable, ranging from 0% to 100% of patients [19] and [26], reflecting differences in tumor characteristics, patient population, or surgeon preference. Lavery et al. studied the performance of NS in HR patients and used visual cues to identify poorly defined planes, bulging of the capsule, or appearance of prostate tissue on the neurovascular bundle [23] . Intraoperative frozen section was also an option to guide NS. In this analysis, NS was performed in 73% of patients, excluding those with biopsy-proven seminal vesicle invasion, extracapsular extension on endorectal coil magnetic resonance imaging (MRI), or high-volume, high-grade disease. Controlling for pathologic disease characteristics, NS was not associated with a higher risk of positive surgical margins or biochemical recurrence. In a separate analysis, Casey et al. showed that NS, either bilateral or unilateral, was not associated with increased positive margins in patients with extraprostatic (pT3) disease [30] .

3.2.2. Lymph node dissection in high-risk prostate cancer

Despite staging and possible therapeutic benefits of lymph node dissection (LND), seven studies (58%) either did not specify the template of dissection or performed limited LND. Reasons for omitting or limiting LND were not stated. Only four RARP studies reported consistent use of extended lymph node dissection (ELND) in HR patients ( Table 2 ). The median lymph node yield from these studies was 18 nodes. Overall lymph node–positive rates ranged from 1% to 33% with the highest rates in the ELND cohorts. Figure 2 depicts a completed ELND during RARP. Of note, robotic ELND did appear to increase operative time with the three series of longest operative time routinely performing ELND [19], [27], and [29]. Table 3 illustrates the complications by study, although reporting methods varied. The rate of symptomatic lymphocele in ELND series was 3% (range: 2.4–6.6%).

Table 2 Summary of high-risk robot-assisted radical prostatectomy series: pathologic outcomes and lymph node dissection

Study Cases, n LN dissection template, % % of patients with LN dissection LN yield LN positive rate, % pT2, n pT2, % Positive margins, %
Shikanov et al. [18] 70 Unspecified 12.9 33 47.1 24.0
Ham et al. [19] 121 Extended 100% 18.6 24.0 21 17.4 48.8
Zugor et al. [20] 147 Unspecified 100% 17.1 47 32.0 33.3
Connolly et al. [21] 160 Limited 27% 14.8 63 39.9 38.0
Yee et al. [22] 62 Unspecified 22.6
Lavery et al. [23] 123 Unspecified 100% 2.4 52 42.3 31.0
Rogers et al. [24] 69 Unspecified 1.4 26 37.7 42.0
Jayram et al. [25] 148 Standard 100% 15 12.3 67 46.0 20.5
Sagalovich et al. [26] 82 Extended 100% 13 13.4 12.0
Yuh et al. [27] 30 Extended 100% 22 33.3 9 30.0 26.7
Ou et al. [28] 148 Unspecified 96% 9 14.2 10 6.8 53.3
Jung et al. [29] 200 Standard: 78/Extended: 23 100% Standard: 15/Extended: 24 Overall: 9/Extended: 22 96 48.0 41.5

LN = lymph node.

All studies were level 4 evidence.


Fig. 2 Intraoperative extended pelvic lymphadenectomy during robot-assisted radical prostatectomy. E = external iliac vessels; I = internal iliac vessels; O = obturator vessels and nerve; OU = obliterated umbilical artery; U = ureter.

Table 3 Summary of high-risk robot-assisted radical prostatectomy (RARP) series: complications of RARP and pelvic lymphadenectomy

Cases, n LN dissection template Lymphocele, % Ileus Anastomotic leakage, % Deep vein thrombosis, % Rectal injury, % Total, % Martin criteria fulfilled
Ham et al. [19] 121 Extended 2.5 2.5 0.8 0.0 1.7 8.3 6
Zugor et al. [20] 147 Unspecified 14.2 8
Rogers et al. [24] 69 Unspecified 5.8 6
Jayram et al. [25] 148 Standard 4 6
Sagalovich et al. [26] 82 Extended 2.4 4
Yuh et al. [27] 30 Extended 6.6 3.3 10.0 3.3 0.0 30.0 7
Ou et al. [28] 148 Unspecified 7.4 6
Jung et al. [29] 200 Standard: 78%/Extended: 23% 3.0 5

LN = lymph node.

All studies were level 4 evidence.

3.3. Perioperative outcomes of robot-assisted radical prostatectomy in high-risk prostate cancer

Table 4 summarizes the operative and postoperative outcomes of RARP. Mean operative time was 168 min, and estimated blood loss was 189 ml. Mean length of hospital stay and catheterization time were 3.2 and 7.8 d, respectively. The average rate of OC disease was 35% (range: 7–48%), and the positive margin rate was 35% (range: 12–53%). Overall complication rates ranged from 3% to 30%, although many series did not fulfill the Martin criteria for complication reporting, and thus events may be underreported.

Table 4 Summary of high-risk robot-assisted radical prostatectomy series: perioperative outcomes

Study Cases Estimated blood loss, ml Operative time, min Hospital length of stay, d Catheter time, d
Ham et al. [19] 121 432 214 5.8 12.9
Zugor et al. [20] 147 183 164 5.7
Lavery et al. [23] 123 84 147 1.6
Rogers et al. [24] 69 150 175 1 7
Jayram et al. [25] 148 150 1 6
Sagalovich et al. [26] 82 150 111
Yuh et al. [27] 30 200 186 1
Ou et al. [28] 148 100 150 3 8
Jung et al. [29] 200 250 190 4

All studies were level 4 evidence.

In studies considering only one clinical variable for HR classification, Zugor et al. compared 147 men with PSA >20 ng/ml with their entire RARP experience. Patients with a high PSA were at a significantly higher risk for non-OC disease, lymph node positivity, and positive margins [20] . For men with Gleason 8–10 on prostate biopsy, lower PSA, lower percentage of positive biopsy cores, and lower biopsy core percentage were all predictive of OC disease. Interestingly, Gleason downgrading was seen in 61% of patients [18] . Ham et al. analyzed 121 men with locally advanced (≥cT3) PCa and did not find an increase in rate of complications, operative time, blood loss, or hospital stay compared with clinically localized patients [19] .

3.4. Functional outcomes: continence and potency

Table 5 and Table 6 summarize the functional results with regard to urinary continence and potency recovery, respectively. NS use, whether unilateral, bilateral, or none, potency definitions, and technique varied among studies, likely contributing to the heterogeneity in reported outcomes. The 12-mo continence rates using a 0–1 safety pad definition ranged from 78% to 95%. Continence with a strict no-pad definition ranged from 51% to 95%, although the study with 51% continence included only men >70 yr of age. Several studies reported statistically significant improvements in the AUA symptom score by 3 points after RARP [22] and [24].

Table 5 Summary of high-risk robot-assisted radical prostatectomy series: continence outcomes

Study Cases, n Continence definition Data source Continence rate, %
6 mo 12 mo 18–36 mo
Yee et al. [22] 62 0–1 pads/d Validated questionnaire 92 (84 with 0 pads)
Lavery et al. [23] 123 0–1 pads/d Validated questionnaire 78
Rogers et al. [24] 69 0–1 pads/d Validated questionnaire 82 (51 with 0 pads)
Jayram et al. [25] 148 0–1 pads/d Unspecified 92
Ou et al. [28] 148 0 pads Surgeon interview 91 95

All studies were level 4 evidence.

Table 6 Summary of high-risk robot-assisted radical prostatectomy series: potency outcomes

Study Cases, n Potency definition Age, yr Nerve sparing, % Evaluation group (%) Data source Potency rate, % Mulhall criteria fulfilled
12 mo 26 mo
Lavery et al. [23] 123 SHIM ≥16 73 (58 BNS; 15 UNS) 72 (59) (preoperatively potent) Validated questionnaire 56 4
Rogers et al. [24] 69 ESI 73 Unclear 21 (30) (preoperatively potent) Questionnaire 33 5
Jayram et al. [25] 148 SHIM ≥17 61 80 (29 BNS; 51 UNS) 100 (68) (preoperatively potent) Validated questionnaire 52 5
Ou et al. [28] 148 ESI 66 20% (9 BNS; 11 UNS) 30 (20) (patients with BNS or UNS) Surgeon interview 60 4

ESI = erections sufficient for intercourse; SHIM = Sexual Health Inventory for Men; BNS = bilateral nerve sparing; UNS = unilateral nerve sparing.

All studies were level 4 evidence.

Erectile function recovery at 12 mo after RARP ranged from 52% to 60%, depending on definition. Potency was 52–56% in two studies that used the validated Sexual Health Inventory for Men questionnaire. One study reported potency rates of 33%, although this was in an older patient cohort [24] . For select HR patients who underwent bilateral NS, Ou et al. found potency rates of 71% [28] . Overall study adherence to the Mulhall criteria was low with only 4 to 5 criteria fulfilled of a possible recommended 11.

3.5. Short-term oncologic outcomes

Table 7 summarizes the rates of additional therapy and early biochemical outcomes according to length of follow-up. Secondary therapy (radiation therapy [RT], ADT, or both) was administered in 9–23% of patients and would be expected to increase with longer follow-up. However, these rates are consistent with open RP series with a 10-yr follow-up showing a 24–65% need for additional therapy [4] .

Table 7 Summary of high-risk robot-assisted radical prostatectomy series: recurrence outcomes

Cases, n Median follow-up, mo Additional therapy (RT and/or ADT), % Definition of biochemical recurrence Recurrence rates, % Time to recurrence, mo
Shikanov et al. [18] 70 9.7 PSA >0.1 1-yr BCRFS: 72 5.7
Zugor et al. [20] 147 19.6 PSA ≥0.2 after nadir or nadir not reached Recurrence free at follow-up: 80
Connolly et al. [21] 160 26.2   PSA >0.2 2-yr BCRFS: 56; 3-yr BCRFS: 45
Lavery et al. [23] 123 12.5 PSA >0.2 Recurrence free at follow-up: 74 4.6
Rogers et al. [24] 69 37.7 13 PSA ≥0.2 with confirmation 1-yr BCRFS: 91; 3-yr BCRFS: 86 9.7
Jayram et al. [25] 148 18 23.3
Ou et al. [28] 148 26.7 PSA >0.2 with confirmation Recurrence free at follow-up: 80
Jung et al. [29] 200 22 9.0 PSA ≥0.2 in consecutive tests Recurrence free at follow-up: 75

ADT = androgen-deprivation therapy; BCRFS = biochemical recurrence–free survival; PSA = prostate-specific antigen; RT = radiation therapy.

All studies were level 4 evidence.

With respect to early biochemical outcomes, Zugor et al. reported a biochemical recurrence–free survival (BCRFS) rate of 80% at 20 mo [20] . Biochemical recurrence occurred in 14–55% of patients with 3-yr BCRFS rates ranging from 45% to 86% [21] and [24]. Mean time to recurrence after RARP ranged from 4.6 to 9.7 mo. Uberoi et al. found that PSA, PSA density, and percentage of positive biopsy cores predicted favorable pathology (OC disease with negative surgical margins) [31] . PSA, clinical stage, pathologic grade [21] as well as evidence of lymph node metastases [29] were found to be significant predictors of biochemical recurrence.

3.6. Discussion

For men with HR PCa, RP represents an option for select patients, and early outcomes of RARP in our systematic review are encouraging. Pathologic outcomes are comparable with a series of 1366 open RP patients examined by Briganti et al., and perioperative and functional outcomes resemble those of RARP in patients without HR disease ( Table 8 ). Rates of secondary therapy and early biochemical recurrence appear similar to open RP. ELND can be performed robotically, and the probability of nodal disease detection increases with more extensive dissection. NS in well-selected patients does not appear to compromise surgical margins or biochemical survival.

Table 8 Comparison of perioperative and pathologic outcomes of radical prostatectomy by technique and risk of disease

Briganti et al. [10] Present analysis Novara et al./Ficarra et al. [13] and [14]
No. of patients 1366 1360
Surgical technique Radical retropubic Robotic Robotic
Risk of disease High risk High risk All
Positive surgical margins 45% 35%
Pathologic stage,%
 pT2 25 35
 pT3a 35 35
 pT3b 33 19
Lymph node yield 10 18 (for ELND)
Lymph node positive rate,% 23 1–33
BCRFS, % 69 (5-yr estimate) 45–86 (3-yr estimate)
Estimated blood loss, ml 189 166
Operative time, min 168 152
Complication rates, % 3–30 3–26
Potency at 12 mo, % 52–60 54–90
Continence (0 pads at 12 mo), % 51–95 84

BCRFS = biochemical recurrence–free survival; ELND = extended pelvic lymph node dissection.

HR PCa represents a wide spectrum of disease depending on the definition used, but generally it denotes men more inclined to experience cancer-related consequences such as progression and death. Prior to the initiation of PSA, patients were more likely to be classified as HR due to an abnormal rectal examination suggesting locally advanced disease [2] . In contrast, nearly 70% of HR patients are now classified as such because of Gleason grade [32] , similar to the 61% in this contemporary review. Currently, no single definition characterizes all men with HR PCa. Instead, clinical stage, Gleason score, and PSA all predict recurrence and progression following primary treatment as well as cancer-related death [5] . Risk group stratification clusters patients that share similar clinical characteristics. Yossepowitch et al. analyzed eight different definitions of HR and found varying rates of biochemical recurrence, need for secondary therapy, metastasis, and death; however, 10-yr PCa-specific mortality did not exceed 11% for any single definition [4] . Nguyen et al. examined six common definitions of HR comprising clinical stage, PSA, biopsy Gleason score, and combinations thereof showing 5-yr BCRFS of 36–58%. Despite considerable differences in patient characteristics, BCRFS did not vary significantly depending on the definition used [33] .

Definitive therapy of HR cancers, often requiring a multimodal approach, appears to provide the greatest long-term survival benefit in patients with ample life expectancy. RT with concomitant ADT has been favored in the treatment of HR PCa without strong comparative evidence due to concerns of functional side effects, high lymph node positive rates, or unresectable disease in HR patients undergoing prostatectomy. Nonetheless, surgical treatment offers a viable alternative to RT plus ADT (NCCN and EAU guidelines [12] ). Multiple retrospective series, controlling for all known variables and selection bias, have suggested superior long-term oncologic outcomes with RP versus RT-based approaches for men with clinically localized HR PCa. Tewari et al. demonstrated significantly lower risk of all-cause or PCa mortality with treatment of high-grade cancer favoring RP over RT [34] . Other population-based studies, adjusting for all measurable variables, have also shown that RP may confer a survival advantage in clinically localized PCa over RT or observation. Zelefsky et al. determined an increase in metastatic progression with RT compared with RP [35] . Cooperberg et al. demonstrated a higher risk of cancer-specific mortality with RT compared with RP [36] . These latter two studies have suggested the greatest comparative survival advantage for surgery over radiation is for patients with HR PCa.

One of the most important benefits of RP as compared with nonsurgical therapy is pathologic staging of the primary cancer as well as regional lymph nodes. Although preoperative risk group stratification and nomograms may identify patients with adverse features, studies have established that pathologic variables such as pathologic Gleason and stage more accurately predict who may benefit from additional therapy [33] . In favorable situations, pathologic downgrading and downstaging at RP may potentially spare patients from receiving adjuvant therapy. About a third of high-grade biopsy Gleason scores (8–10) are subsequently downgraded at RP, and 26–31% will have OC disease [37] . Moreover, several authors have observed significant differences in outcomes with Gleason grade 8 compared with grade 9 disease, reflecting variable disease biology [11] and [38]. For example, Wambi et al. in an RARP series found 5-yr BCRFS rates of 47% for Gleason 8 and 21% for Gleason 9 disease [38] . Lymphadenectomy at the time of RP confers information about the level and extent of nodal involvement and may guide initiation of earlier adjuvant ADT. Multiple series suggest an approximately 10–20% 10-yr disease-free recurrence without adjuvant therapy following LND for men with lymph node metastases [39] .

A pelvic LND for PCa has diagnostic, prognostic, and possibly therapeutic intent. Multiple series have suggested the extent and quality of a pelvic LND is not dependent on a specific surgical technique; rather, nodal yield is far more dependent on surgeon intent rather than the technical approach (open, laparoscopic, or robotic) [40] . The specific template of dissection for ELND remains a topic of debate. The EAU recommends that if a LND is to be performed, it should be an ELND [12] . Higher nodal yield provides more accurate staging. Abdollah et al. determined that with the removal of 20 lymph nodes, about 90% of patients were properly staged [41] . Burkhard et al. revealed up to 58% of patients with nodal invasion had metastases in the internal iliac nodes [42] . Therefore, at minimum, the nodes overlying the external iliac and internal iliac vessels and obturator fossae should be removed for ELND ( Fig. 3 ). Recent interest in replicating the open standard of pelvic LND with the surgical robot has demonstrated increases in nodal yield and detection of positive lymph nodes compared with a more limited dissection [27] . Categorically, this improves staging and removes cancerous tissue that may lead to biochemical recurrence or metastatic disease. Robotic ELND can safely achieve lymph node yields of 16–24 nodes [27] and [29]. Operative timing of LND has been described either initially [29] , after posterior dissection is completed [27] , or after the vesicourethral anastomosis is complete. Several studies have showed an improvement in survival with LND that may be secondary to the removal of micrometastatic disease [43] . In a study of men randomized to extended or standard LND, HR patients experienced improved 6-yr BCRFS with ELND (71% vs 51%) [44] . In a longitudinal series of 406 patients undergoing limited or extended LND, no significant difference in overall or major complication rates was demonstrated [45] . Large randomized trials of extended versus limited LND have not been performed, although complication or erectile function rates may be affected by more extensive dissection [26] . Longer follow-up will be needed to determine the therapeutic benefits of ELND.


Fig. 3 Template of dissection for extended pelvic lymphadenectomy.

Another potential benefit of RP for HR PCa is the possible posttreatment avoidance of additional therapy. Approximately half of men will require multimodal therapy, either delivered in an adjuvant or salvage manner. Yossepowitch et al. found that 35–76% of HR patients avoided secondary therapy altogether 10 yr after surgery [4] . Increased scrutiny of prolonged systemic hormone therapy has revealed many detrimental side effects including osteoporosis, decreased libido and erections, hot flashes, fracture risk, and potential cardiovascular morbidity [46] . Men receiving RT for HR PCa are 3.5 times more likely to receive ADT than patients treated with RP [2] . For HR disease, primary treatment with RP has a 70% chance of avoiding ADT [47] . Boorjian et al. showed an increased risk of all-cause mortality with RT plus ADT compared with RP, potentially attributable to ADT morbidity or inferior cancer control [48] . Even if men ultimately require salvage androgen deprivation for disease control after RP, they may delay time to the initiation of ADT. The median time from RP to salvage ADT in the previously mentioned study was 10.3 yr.

Another advantage of RP is the expectation and significance of a nondetectable PSA. After RP in completely excised patients, serum PSA should decline to a nondetectable level. The sensitivity of post-RP PSA provides a prompt assessment of disease cure and control, allowing early recognition of recurrent disease and delivery of salvage RT if necessary. PSA kinetics after primary RT are less predictable, which could delay the recognition of recurrence for years. In a large comparative analysis, median time to salvage therapy following RP was 13 mo versus 69 mo for RT [35] . Primary treatment with RP allows for salvage RT with curative intent in the setting of a promptly recognized local recurrence. Even in patients with poorly differentiated disease and positive margins, recurrence after RP can be effectively treated with salvage radiation that may prevent metastatic progression. Long-term overall survival and CSS in patients requiring multimodal therapy remains excellent.

Historically, clinicians performing RP for HR patients recommended wide resection on the side of the disease [7] due to concerns for positive surgical margins. With contemporary HR tumor characteristics trending toward more OC disease, selective NS during RARP appears technically attainable and oncologically safe. Preoperative endorectal coil MRI has not been shown to predict T3 disease consistently at RARP [49] . Overall, a combination of considerations such as digital examination, high-resolution MRI, baseline potency, and intraoperative findings should guide NS.

Younger (<59 yr), healthier patients with HR PCa are most likely to benefit from RP [50] . Curative treatment with RP is ideally suited for HR patients with OC disease. In a multi-institutional series of 1366 HR men, 37% had OC disease [19] , which is similar to the 35% rate in RARP from the present review. Despite this seemingly low rate, their entire cohort experienced excellent CSS of 91% at 10 yr after RP. Other reasons beyond stage migration that more HR patients may now present with OC disease are improvements in imaging and resultant patient selection.

The role of RARP for HR PCa will be better understood as larger series mature and longer follow-up is available. Regardless of treatment approach, improving cure rates for HR PCa depends on earlier recognition of men destined to have locally advanced disease and supporting randomized trials of novel neoadjuvant and adjuvant treatment strategies. RARP offers a minimally invasive option to primary treatment of HR PCa with early outcomes that appear similar to open RP.

There are several limitations to this review including study heterogeneity, generally short follow-up, and lack of individual patient data. Overall oncologic follow-up of patients is short in all studies; therefore definitive interpretation of survival data are not possible at this time. Although the summarized data appear comparable to open RP series, there are no side-by-side analyses. Certain data such as LND template are missing in several studies, although nodal counts may serve as a surrogate for extent of dissection. No consensus agreement regarding adjuvant therapy for HR patients treated with RP has been determined. Accordingly, rates of adjuvant and salvage RT or ADT varied that could have a downstream effect on survival outcomes. For the individual patient, assessment of disease may be most effective using established nomograms, although many were derived in the era of limited LND that understages HR patients.

4. Conclusions

RARP appears to be a safe and effective option for selected patients with HR PCa either alone or as the initial step in a multimodal treatment plan. Neurovascular bundle preservation is feasible in selected cases and may improve functional outcomes. Extended lymphadenectomy improves staging, increases detection of positive lymph nodes, and can be done safely and thoroughly robotically. Further longitudinal study is required to assess the long-term survival benefit of primary RARP in men with HR PCa.

Author contributions: Bertram Yuh had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Yuh, Novara, Zorn, Wilson, Kimm, Touijer, Artibani, Heidenreich, Tewari, Menon, Eggener.

Acquisition of data: Yuh, Novara, Zorn, Wilson, Kimm, Touijer, Artibani, Heidenreich, Menon, Eggener.

Analysis and interpretation of data: Yuh, Novara, Zorn, Wilson, Kimm, Touijer, Artibani, Heidenreich, Tewari, Menon, Eggener.

Drafting of the manuscript: Yuh, Novara, Zorn, Wilson, Kimm, Touijer, Artibani, Heidenreich, Tewari, Menon, Eggener.

Critical revision of the manuscript for important intellectual content: Yuh, Novara, Zorn, Wilson, Kimm, Touijer, Artibani, Heidenreich, Tewari, Menon, Eggener.

Statistical analysis: Yuh, Novara, Zorn, Eggener.

Obtaining funding: None.

Administrative, technical, or material support: Yuh, Novara, Zorn, Wilson, Kimm, Touijer, Artibani, Heidenreich, Tewari, Menon, Eggener.

Supervision: Novara, Zorn, Wilson, Kimm, Touijer, Artibani, Heidenreich, Menon, Eggener.

Other (specify): None.

Financial disclosures: Bertram Yuh certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None.

Funding/Support and role of the sponsor: None.


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a City of Hope Cancer Center, Duarte, CA, USA

b University Hospital of Verona, Verona, Italy

c University of Aachen, Aachen, Germany

d Memorial Sloan-Kettering Cancer Center, New York, NY, USA

e Henry Ford Hospital, Detroit, MI, USA

f University of Padua, Padua, Italy

g Weill Cornell Medical College, New York, NY, USA

h University of Montreal Hospital Center, Montreal, Canada

i University of Chicago Medicine and Biological Sciences, Chicago, IL, USA

lowast Corresponding author. City of Hope National Cancer Center, Urologic Oncology, 1500 E. Duarte Road, Duarte, CA 91010, USA. Tel. +1 626 256 4673; Fax: +1 626 301 8285.

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