Long-term Cancer Control Outcomes After Robot-assisted Radical Prostatectomy in Pathologically Non-organ-confined High-risk Prostate Cancer: 20-year Report from a Single Tertiary Referral Center.

[BACKGROUND AND OBJECTIVE] Exhaustive evidence on the long-term efficacy of robot-assisted laparoscopic prostatectomy (RALP) in non-organ-confined high-risk prostate cancer (PC) is still lacking. Our aim was to evaluate long-term oncological outcomes in this subset of patients treated with RALP at a single referral center.

[METHODS] We included 803 patients with pathologically non-organ-confined high-risk PC (≥pT3a and/or pN1) at RALP between 2001 and 2022 at Henry Ford Hospital (Detroit, MI, USA). All patient underwent RALP using the Vattikuti Institute technique, with or without extended pelvic lymph node dissection (external iliac, obturator, and internal iliac nodes). The Kaplan-Meier method was used to estimate overall survival (OS) and additional treatment-free survival. The probability of PC-specific survival (PCSS) was estimated via the competing-risks method. Competing-risk and Cox regression analyses were used to identify potential predictors of PC-specific mortality (PCSM), any-cause mortality (ACM), and additional treatment.

[KEY FINDINGS AND LIMITATIONS] We included 803 patients, of whom 415 (51.5%) had pT3a, 385 (47.9%) had ≥pT3b, 323 (40%) had pN1, and 670 (84%) had grade group 4-5 PC. Of the 635 patients with status information regarding additional treatment, 416 received further therapy after surgery. Specifically, 46, 110, and 260 underwent RT only, HT only, or RT + HT, respectively. Median follow-up was 72 mo (interquartile range 28-120). The 20-yr survival rates were 72.7% (95% confidence interval [CI] 56.8-86,5%) for PCSS and 45.2% (95% CI 29.1-60.1%) for OS. The rates of survival free from additional treatment were 31.3% (95% CI 26.1-36.5%) at 10 yr and 20.3% (95% CI 14.9-26.4%) at 15 yr. Multivariable regression revealed pT3b-4 stage as an independent predictor of PCSM (hazard ratio [HR] 2.50; p = 0.008), ACM (HR 1.84; p = 0.006), and additional treatment (HR 1.69; p < 0.001).

[CONCLUSIONS AND CLINICAL IMPLICATIONS] For patients with non-organ-confined high-risk PC, RALP achieves long-term oncological control. This study provides the longest follow-up after RALP as the primary local treatment for patients with truly aggressive PC forms and offers valuable insights for patient counseling on long-term outcomes.