# Robot-Assisted Radical Prostatectomy for Locally Advanced Prostate Cancer: Oncological Potential and Limitations as the Primary Treatment

## TL;DR

This study examines the effectiveness of robot-assisted surgery alone for advanced prostate cancer, finding it can work for some patients but not all.

## Contribution

The study evaluates robot-assisted radical prostatectomy as a standalone treatment for locally advanced prostate cancer, identifying key patient characteristics for success.

## Key findings

- Five-year survival rates were 36.6% for biochemical recurrence-free survival and 88.9% for metastasis-free survival.
- Patients with high PSA, advanced stage, or multiple high-grade biopsy cores had worse outcomes.
- Surgery alone provided durable cancer control for selected patients, but others needed additional therapies.

## Abstract

Prostate cancer is one of the most common cancers in men, and those with locally advanced disease are often treated with a combination of surgery, radiation, and systemic therapy. However, the long-term benefits of surgery alone are less clear. This study aimed to assess the safety and outcomes of robot-assisted radical prostatectomy (RARP) performed without additional systemic treatment. We analyzed 258 men with high-risk features—such as advanced clinical stage, high PSA levels, or aggressive biopsy results—who underwent RARP between 2012 and 2022. After a median follow-up of approximately 5 years, the 5-year survival rates were 36.6% for biochemical recurrence-free survival, 88.9% for metastasis-free survival, and 98.3% for cancer-specific survival. Factors linked to poorer outcomes included very high PSA, advanced stage, multiple high-grade biopsy cores, lymphovascular invasion, and lymph node involvement. These findings suggest that surgery alone may be effective for select patients, whereas multimodal therapy would be required in others.

Background: Locally advanced prostate cancer (PCa) is commonly treated with multimodal therapy; however, long-term outcomes of surgery alone are poorly defined. We investigated the potential and limitations of robot-assisted radical prostatectomy (RARP) as primary treatment without perioperative systemic therapy in patients with locally advanced PCa. Methods: We retrospectively analyzed 258 patients who underwent RARP with extended pelvic lymph node dissection between 2012 and 2022 with locally advanced PCa, defined as present if at least one of the following was met: clinical stage cT3b–T4; primary Gleason pattern 5; >4 biopsy cores with Grade Group 4 or 5; or more than one NCCN high-risk characteristic. Patients who received neoadjuvant or adjuvant therapy were excluded. Endpoints included biochemical recurrence-free survival, metastasis-free survival, cancer-specific survival, and predictors of persistent PSA. Results: Median follow-up was 60.6 months. Pathological stage ≥ pT3a occurred in 63.6% and nodal involvement (pN1) in 27.1%. Five-year BRFS, MFS, and CSS were 36.6%, 88.9%, and 98.3%, respectively. Persistent PSA occurred in 21.3%. Preoperative predictors included PSA > 40 ng/mL, clinical stage ≥ cT3a, and >4 biopsy cores with a Gleason score of 8–10; patients with ≥2 features had significantly poorer BRFS and MFS. Postoperative predictors of recurrence were pathological stage, lymphovascular invasion, and nodal involvement. Conclusions: RARP alone provided durable long-term cancer control in selected men with locally advanced PCa, whereas patients with multiple adverse features were unlikely to be cured with surgery alone. Careful risk stratification may identify candidates for surgical monotherapy and help avoid overtreatment, while others may benefit from multimodal therapy.