Robot-Assisted Salvage Prostatectomy: External Validation of the EAU Selection Criteria and Identification of the Optimal Candidate: A Junior ERUS/YAU Collaborative Study

Abstract

Background: EAU guidelines recommend salvage radical prostatectomy (sRP) only in highly selected patients with recurrent prostate cancer in experienced centers. Methods: The Junior ERUS/Young Academic Urologist Working Group on Robot-Assisted Surgery conducted a multicentric project to investigate biochemical recurrence-free (BCR), metastases-free (MFS), and overall survival (OS) outcomes in robotic sRP patients stratified according to EAU criteria. Results: Of 180 patients, 49% fulfilled EAU criteria. Patients not fulfilling EAU criteria more frequently underwent focal therapy as primary treatment (53% vs. 33%) and exhibited significantly higher rates of pT3–4 (70% vs. 48%), positive surgical margins (48% vs. 24%), and pathological Gleason score 8–10 (72% vs. 48%, all p < 0.01), with no differences in postoperative complications. Rates of PSA persistence were significantly higher in patients not fulfilling EAU criteria (16% vs. 0%, p < 0.001). Regarding BCR, patients not fulfilling EAU criteria harbored significantly worse BCR-free survival (hazard ratio (HR): 1.96, p = 0.046) with 24- and 48-month BCR-free survival rates of 81.7% and 73.9% vs. 65.0% and 58.5% for patients fulfilling EAU criteria. After multivariable adjustment, patients not fulfilling EAU criteria harbored higher risk of BCR (HR: 2.94, p = 0.045). Regarding MFS and OS outcomes, no significant differences were observed in the comparison between both groups. Incorporating presalvage surgery features into a new classification yielded better discrimination for BCR analysis, but were comparable to EAU criteria for MFS and OS outcomes. Conclusions: The majority of patients do not fulfill EAU criteria, and even more so after focal therapy. These patients harbor worse BCR rates after robotic sRP. However, within our short-term follow-up, no differences in MFS and OS were observed.