title: Robot-assisted Radical Prostatectomy and Extended Pelvic Lymph Node Dissection in Patients with Locally-advanced Prostate Cancer.
abstract: Limited data are available on the role of robot-assisted radical prostatectomy (RARP) in patients with locally advanced prostate cancer (PCa).
  
  
  
  To describe our surgical technique of extrafascial RARP and extended pelvic lymph node dissection (ePLND) in locally advanced PCa.
  
  
  
  Ninety-four patients with clinical stage ≥T3 undergoing RARP with ePLND at three European centers between 2011 and 2015 were retrospectively evaluated.
  
  
  
  Surgery was performed using the DaVinci Si system. The anatomically defined ePLND included nodes overlying the external iliac axis, those in the obturator fossa, and around the internal iliac artery up to the ureter. RARP was performed using an extrafascial approach where the Denonvillers' fascia was dissected free and left on the posterior surface of the seminal vesicles.
  
  
  
  Perioperative outcomes consisted of operative time, blood loss, length of hospital stay, and complications occurred within 30 d after surgery. Biochemical recurrence (BCR) was defined as two consecutive prostate-specific antigen values ≥0.2ng/ml. Kaplan-Meier analyses assessed time to BCR and clinical recurrence. Multivariable Cox regression analyses assessed predictors of BCR.
  
  
  
  Median operative time, blood loss, and length of hospital stay were 230min, 200ml, and 6 d. Overall, 12 (12.7%) patients experienced complications and five (5.3%), four (4.3%), and three (3.2%) patients had Clavien I, II, and III/IV complications. Overall, 72 (76.6%), 35 (37.2%), and 30 (32.3%) patients had pT3/4, pN1, and positive margins. The median number of nodes removed was 16. Overall, 19 (20.2%) and 21 (22.3%) patients received adjuvant radiotherapy and hormonal therapy. The median follow-up was 23.5 mo. At 3-yr follow-up, the BCR- and clinical recurrence-free survival rates were 63.3% and 95.8%. Pathologic stage, Gleason score, and positive margins represented predictors of BCR (all p≤0.03). Our study is limited by its retrospective nature and by the follow-up duration.
  
  
  
  RARP represents a well-standardized, safe, and oncological effective option in patients with locally advanced PCa. Pathologic stage, Gleason score, and positive margins should be considered to select patients for multimodal approaches.
  
  
  
  Robot-assisted surgery represents a well-standardized, safe, and oncological effective option in men with locally advanced prostate cancer. Two out of three patients treated with this approach are free from recurrence at 3-yr follow-up. Pathologic stage, Gleason score, and positive surgical margins represent predictors of BCR and should be considered to select patients for multimodal approaches.
authors.affiliation: Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; Department of Urology, Vita-Salute San Raffaele University, Milan, Italy; OLV Vattikuti Robotic Surgery Institute, Melle, Belgium. Electronic address: giorgio.gandaglia@gmail.com.
authors.forename: Giorgio
authors.initials: G
authors.lastname: Gandaglia
authors.affiliation: Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.
authors.forename: Elisa
authors.initials: E
authors.lastname: De Lorenzis
authors.affiliation: OLV Vattikuti Robotic Surgery Institute, Melle, Belgium.
authors.forename: Giacomo
authors.initials: G
authors.lastname: Novara
authors.affiliation: Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; Department of Urology, Vita-Salute San Raffaele University, Milan, Italy; OLV Vattikuti Robotic Surgery Institute, Melle, Belgium.
authors.forename: Nicola
authors.initials: N
authors.lastname: Fossati
authors.affiliation: Department of Urology, Onze-Lieve-Vrouw Hospital, Aalst, Belgium.
authors.forename: Ruben
authors.initials: R
authors.lastname: De Groote
authors.affiliation: OLV Vattikuti Robotic Surgery Institute, Melle, Belgium.
authors.forename: Zach
authors.initials: Z
authors.lastname: Dovey
authors.affiliation: Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; Department of Urology, Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Nazareno
authors.initials: N
authors.lastname: Suardi
authors.affiliation: Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; Department of Urology, Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Montorsi
authors.affiliation: Division of Oncology/Unit of Urology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; Department of Urology, Vita-Salute San Raffaele University, Milan, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Briganti
authors.affiliation: Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy.
authors.forename: Bernardo
authors.initials: B
authors.lastname: Rocco
authors.affiliation: OLV Vattikuti Robotic Surgery Institute, Melle, Belgium.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Mottrie
mesh_terms: D000368:Aged; D005205:Fascia / Q000473:pathology; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D010388:Pelvis / Q000473:pathology*; D011468:Prostatectomy / Q000379:methods* / Q000401:mortality; D011471:Prostatic Neoplasms / Q000401:mortality / Q000473:pathology*; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures
keywords: Extended pelvic lymph node dissection; Locally advanced; Prostate cancer; Radical prostatectomy; Robot assisted