title: Feasibility of robot-assisted radical prostatectomy for very-high risk prostate cancer: surgical and oncological outcomes in men aged ≥70 years.
abstract: OBJECTIVE
  Robot-assisted radical prostatectomy with pelvic lymph node dissection (RALP-PLND) is a feasible treatment option for high-risk prostate cancer (HPCa), but remains controversial for very high-risk prostate cancer (VHPCa). We aimed to assess the feasibility of RALP-PLND in men ≥70 years with VHPCa features by comparing outcomes to those of HPCa.
  
  
  METHODS
  Among patients aged ≥70 years who underwent RALP-PLND between 2005 and 2012, 101 HPCa patients (31%) (PSA≥20 ng/mL or biopsy Gleason 8-10 or cT3a) and 53 VHPCa patients (16%) (≥cT3b or cN1) were identified. Perioperative, functional, and oncological outcomes were compared between groups.
  
  
  RESULTS
  Perioperative outcomes including operative time (P=0.917), estimated blood loss (P=0.181), and complications (P=0.239) were comparable. Due to Gleason score downgrading, 19% of HPCa and 4% of VHPCa were actually of intermediate risk. VHPCa revealed higher LN involvements (P=0.002). Discrepancy between clinical and pathological nodal status was more frequent in VHPCa (36% vs. 7%, P<0.01). Nodal metastasis would have been missed in 23% patients without PLND, while 13% of cN1 patients were shown to be metastasis-free by PLND. Continence rates were lower for VHPCa (32% vs. 56%, P=0.013). Although biochemical recurrence-free survival rates were comparable (P=0.648), risk for later adjuvant treatments was higher for VHPCa patients (14% vs. 34%, P<0.01).
  
  
  CONCLUSIONS
  RALP-PLND is a feasible option for VHPCa in elderly patients with satisfactory oncologic outcomes; however, functional outcomes were not as favorable. Patients who are unable to accept the risk of adjuvant therapy and its side effects or incontinence should be deterred from surgical treatment, and other options such as radiation therapy could be an alternative.
authors.affiliation: Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Kyo Chul
authors.initials: KC
authors.lastname: Koo
authors.affiliation: Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Dae Chul
authors.initials: DC
authors.lastname: Jung
authors.affiliation: Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Seung Hwan
authors.initials: SH
authors.lastname: Lee
authors.affiliation: Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Young Deuk
authors.initials: YD
authors.lastname: Choi
authors.affiliation: Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Byung Ha
authors.initials: BH
authors.lastname: Chung
authors.affiliation: Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Sung Joon
authors.initials: SJ
authors.lastname: Hong
authors.affiliation: Department of Urology, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea.
authors.forename: Koon Ho
authors.initials: KH
authors.lastname: Rha
keywords: Aged; Prostate neoplasms; Robotics; Treatment outcome