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the retroperitoneal stations. The median number of nodes
removed in these patients was 16. Data on PSA values at
40 d after surgery were available for 15 patients included in
the study. Overall, five (33.3%) patients experienced BR.
When patients were stratified according to nodal stage at
RP, two (25.0%) and three (42.9%) had pN0/x and pN1
disease, respectively (p = 0.3). Overall, eight (50.0%) patients
received ADT after RASND.
4. Discussion
A non-negligible proportion of patients with clinically
localized PCa treated with RP will experience recurrence
during follow-up . In the last few years, the availability of
novel imaging modalities such as choline and PSMA PET/CT
scans allowed clinicians to reliably identify the site of
recurrence even at low PSA levels and the
regional lymph nodes represent one of the most common
sites of recurrence after RP . Although ADT and
systemic therapies were historically considered as the
standard of care in these patients, men with recurrence
limited to the pelvic and/or retroperitoneal lymph nodes
would harbor a favorable prognosis compared with their
counterparts with visceral or skeletal involvement
This led to the hypothesis that metastases-directed
therapies might represent safe and effective options in this
setting. Recent studies supported the role of salvage lymph
node dissection in patients with nodal recurrence after RP
. However, these series focused on men treated with
open approaches and no data are available on minimally
invasive pelvic and retroperitoneal salvage lymph node
dissection. Under this light, we aimed at describing the
surgical technique and outcomes of RASND in PCa patients
with nodal recurrence after RP documented by PET/CT scan.
Several results of our study are noteworthy. Firstly, our
investigation demonstrates that RASND is a feasible
procedure with a relatively low morbidity and no perioper-
ative mortality when performed by two high-volume
robotic surgeons in tertiary referral centers. Although one
out of four patients included in our study experienced
intraoperative complications related to ureteral or vascular
injuries, no high-grade complications, transfusions, and
reoperations were recorded in the postoperative period.
Moreover, patients treated with RASND had a relatively low
blood loss and a short LoS. When focusing on nodal
dissection-related complications, only two patients experi-
enced lymphedema or lymphorrhoea and were managed
conservatively. These results are promising when compared
with what was observed in open series, where lymphoceles
requiring drainage occurred in up to 14% of the patients and
surgical reintervention was necessary in approximately 3%
of the cases . The lower morbidity associated with
RASND might be related to the potential advantages of
minimally invasive approaches in terms of reduced surgical
trauma, improved precision, lower risk of bleeding, and
better visualization and control of lymphatic vessels.
Nonetheless, due to the learning curve phenomenon and
to possible difficulties related to the salvage nature of this
surgical approach, RASND should be considered as a safe
procedure only in the hands of experienced surgeons in
high-volume centers. Indeed, patients considered for this
surgical treatment represent a population at higher risk of
complications due to previous abdominal surgery, nodal
dissection and, possibly, pelvic radiotherapy . In this
context, it is worth highlighting that in our series three
intraoperative vascular injuries were recorded. All these
cases were managed robotically and did not result into
conversion or high-grade complications in the postopera-
tive period.
Secondly, an anatomically defined extended nodal
dissection that included the pelvic and retroperitoneal
stations was feasible and resulted in the detection of
positive lymph nodes in up to 70% of patients included in
our cohort. Although RASND was guided by choline or PSMA
PET/CT scans, the dissection was not limited to positive
spots at preoperative imaging and was extended to the
pelvic and, in the majority of cases, retroperitoneal nodal
stations. Recent investigations demonstrated that Choline
and, in particular, PSMA PET/CT scans have good detection
rates and accuracy in the identification of the site of
recurrence after primary treatment even at low PSA levels
However, these imaging modalities might under-
estimate nodal tumor burden, where only 35% of patients
undergoing salvage nodal dissection guided by choline PET/
CT scan have lymph node metastases limited to the positive
spots at preoperative imaging . Therefore, when a
salvage nodal dissection is considered, it should be
extended to all regional lymph node stations and not
limited to the sites of positive spots at preoperative imaging
Table 3 – Pathological results and follow-up data of patients
treated with robot-assisted salvage nodal dissection (RASND) for
nodal recurrent prostate cancer after radical prostatectomy
Variable Value
Patients with positive lymph nodes at RASND (%) 11 (68.8)
Site of LND (%)
Pelvic 3 (18.7)
Retroperitoneal 1 (6.3)
Pelvic plus retroperitoneal 12 (75.0)
Total no. of lymph nodes removed
Median (IQR) 16.5 (6–23.7)
Total no. of positive lymph nodes
Median (IQR) 4 (1–5)
Location of recurrence (%)
Obturator and internal iliac 5 (45.5)
External iliac 1 (9.1)
Common iliac 4 (36.4)
Preaortic 2 (18.2)
Paraortic 4 (36.4)
Interaortocaval 3 (27.3)
Patients with positive pelvic lymph nodes only (%) 6 (54.5)
Patients with positive retroperitoneal lymph
nodes only (%)
2 (18.2)
Patients with positive pelvic + retroperitoneal
lymph nodes (%)
3 (27.3)
Biochemical response after RASND (% 5 (33.3)
Adjuvant ADT after RASND (%) 8 (50.0)
ADT – androgen deprivation therapy; IQR = interquartile range; LND =
lymph node dissection.
a Data available for n = 15 patients.
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