EURURO Vol. 72 No. 3

439 476

Editorial
Referring to the article published on pp. 432–438 of this issue
Salvage Surgery for Nodal Recurrence of Prostate Cancer:
Might the Robotic Approach Render an Experimental
Procedure More Acceptable?
Riccardo Schiavina, Lorenzo Bianchi Marco Borghesi, Giuseppe Martorana,
Eugenio Brunocilla
Department of Urology, University of Bologna, Bologna, Italy
Oncologic failure after radical prostatectomy (RP) repre-
sents one of the main downfalls of prostate cancer (PCa)
surgery. Positron emission tomography (PET)/computed
tomography (CT) has revolutionized clinical management
of PCa via better and earlier assessment of the site and
extension of recurrence for lower disease burden, opening
the way to the novel concept of metastasis-directed
therapy. The oligometastatic state includes patients who
differ in prognosis according to the site of recurrence: men
with nodal-only recurrence have better prognosis than men
with skeletal or visceral metastases . In this context, the
hypothesis that nodal debulking with removal of all tumour
foci could maximize disease control was supported by
several retrospective studies of patients undergoing salvage
lymph node dissection (sLND) after primary treatment
. In fact, even though salvage surgery for recurrent PCa
still represents an experimental approach, increasing
numbers of European and American centres currently
consider sLND for selected patients, as reflected by an
increase in the literature in recent years.
The vast majority of studies investigating the thera-
peutic benefit of sLND are based on open surgery, while
results for the robotic approach are anecdotal . In this
issue of European Urology, Montorsi and colleagues are
the first to report perioperative, pathologic, and early
oncologic outcomes of robot-assisted salvage lymph node
dissection (RASND) in a series of 16 patients with pelvic
and/or retroperitoneal nodal PCa recurrence after RP. The
authors are commended for exploring a very challenging
issue at the forefront in urology — sLND — involving
pioneering use of a robotic system never investigated
before, with promising surgical outcomes in terms of
median operative time (210 min), blood loss (250 ml), and
hospital stay (3.5 d). Preliminary oncologic data are also
encouraging: approximately 30% of the individuals had
complete biochemical response (BR) at 40 d after surgery.
Despite lacking data concerning biochemical recurrence
(BCR)–free and clinical recurrence (CR)–free survival, the
authors suggest that the robotic approach could be as
effective as open sLND for cancer control, since half of the
patients did not receive androgen deprivation therapy
(ADT) immediately after surgery. Indeed, the proportion of
patients with nodal involvement, the number of lymph
nodes removed, and the number of positive lymph nodes
were comparable to data for open series Overall,
RASND resulted in a safer procedure, with low complica-
tions rates, no grade III–V complications observed,
and only 6.3% of patients experiencing lymphoedema/
lymphorrhea. On the contrary, open sLND can be a very
invasive procedure, as it can involve xiphopubic abdomi-
nal incision and is not free from complications, including
lymphorrhea (15.3%), fever (14.5%), and ileus (11.2%), that
have a negative influence on recovery times and could
require reintervention in up to 3% of cases . Since open
surgery is considered an aggressive approach, some
authors have proposed other types of salvage therapy,
ava ilable at
journal homepage:
DOI of original article: .
* Corresponding author. Department of Urology, University of Bologna, S. Orsola-Malpighi Hospital, Bologna, Italy. Tel. +39 051 6362747;
Fax: +39 051 6362535.
E-mail address: (L. Bianchi).
0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.