Optimizing oncological and functional outcomes with wide resection techniques in robot-assisted radical prostatectomy for very high-risk prostate cancer: A single-institution retrospective study

Objectives: To assess our wide resection robot-assisted radical prostatectomy techniques in very high-risk prostate cancer. Methods: Among 600 patients, we identified 63 patients with localized or locally advanced very high-risk prostate cancer (cT3b-T4, primary Gleason pattern 5, multiple high-risk features, or >= 5 positive biopsy cores with Grade Group 4-5 pathology) undergoing wide resection robot-assisted radical prostatectomy following six months of vintage hormonal therapy between 2019 and 2023. Clinical staging included digital rectal exams, magnetic resonance imaging, computed tomography, and bone scintigraphy. We assessed the effectiveness of our wide resection techniques in reducing PSM rate by evaluating the perioperative, pathological, and oncological outcomes. Results: The overall PSM rate was 19% (6.7% for pT2, 9.1% for pT3a, and 47% for pT3b). The most frequent site for extracapsular extension was the lateral side (30%), followed by the bladder neck (26%). The bladder neck was the most common location of PSM (59%). Over a median follow-up of 18.7 months, patients without PSMs had a 46% higher 2-year prostate-specific antigen-free survival rate than those with PSMs. One patient experienced Clavien-Dindo grade IIIa deep vein thrombosis, and 51% achieved immediate continence. A limitation of this study was the use of vintage hormonal therapy and conventional imaging modalities. Conclusions: Our study demonstrated that wider bladder neck dissection, rather than wider apical dissection, can achieve acceptable short-term functional and oncological outcomes. Future studies with longer follow-up are warranted to assess effectiveness of wide resection for local cancer control in very high-risk prostate cancer as a part of a multimodality strategy.