EURURO Vol. 72 No. 3

440 476

such as radiotherapy targeted to lesions (nodal and/or
skeletal), in attempts to achieve local control of disease.
Data from radiation therapy series reported BR rates and
BCR-free survival rates similar to those for surgical cohorts
, but these studies are limited by relatively short follow-
up (< 30 mo), different fractionation schedules that reflect
a lack of standardised radiation protocols, and non-
negligible radiation toxicity (grade 2 gastrointestinal
toxicity up to 6.6% and grade 3 genitourinary toxicity
26.3% ). In this context, the robotic approach may
render salvage nodal debulking more acceptable in the
near future.
Can we generalize the robotic approach for nodal
recurrence of PCa? Unfortunately, this is not yet possible.
In fact, RASND should be considered very highly complex
surgery because of previous abdominal surgery (RP and
pelvic LND), adjuvant/salvage radiotherapy, and tissue
alterations due to ADT. To underline this concept, an
intraoperative aortal injury with sudden robotic vessel
suturing is depicted in the video presented by the authors
Such difficult robotic management of an intraoperative
complication with no surgical conversion would be safe only
in the hands of very skilled surgeons. In fact, extended
retroperitoneal dissection with anatomical vessel exposure
from iliac bifurcation to the renal arteries comprises many
dangerous steps, and inexperienced robotic surgeons might
encounter complications that could be catastrophic if not
adequately managed. For these reasons, RASND should only
be performed in high-volume centres by very experienced
robotic surgeons.
This novel approach further underlines the need to
perform an extended lymph node dissection in every
patient with high-risk disease at the time of primary RP.
It is certainly preferable to perform RASND in a virgin
operating field than after a first dissection in which only a
few nodes were removed, for which the risk of adherences
and vascular complications is certainly higher.
The key point when considering salvage therapy for PCa
recurrence is correct identification of individuals who could
gain the most benefit from this type of surgery. Stressing
this point, previous retrospective open sLND series under-
lined the need to consider the main significant predictors of
recurrence after surgery: individuals with retroperitoneal
lymph node involvement, prostate-specific antigen (PSA)
4 ng/ml at the time of sLND, and more than two positive
lymph nodes are more likely to experience the worst
oncologic control . In this context, PET/CT with choline or
[68Ga]-labelled prostate-specific membrane antigen
(PSMA) still suffers from suboptimal performance:
when choline PET/CT can identify just one lesion, other
metastases usually remain undetected in most cases
. Furthermore, [68Ga]-PSMA PET/CT, despite better
diagnostic accuracy compared to choline, is limited by
false positive results in up to 30% of cases . Thus, the
dissection template should not be limited to imaging results
, although the question of whether to extend dissection
to the retroperitoneum remains a matter of debate.
Considering the poor prognosis for patients with nodal
metastases in the retroperitoneal space , men with
multiple retroperitoneal focal uptake points might not the
best candidates for surgery. On the contrary, in the case of
focal uptake in the pelvis, extension of dissection to the
retroperitoneal space could remove some microscopic
cancer deposits not detected by imaging and not revealed
by standard pathologic analyses , which could result in
a survival benefit.
Finally, it has been well demonstrated that the
vast majority of PCa patients with BCR after RP have
negative imaging findings, especially for men with low
PSA levels, but harbour microscopic tumour deposits
within the lymphatic system. It is possible that these
patients with early BCR and micrometastatic disease but
negative scans are the ‘‘real oligometastatic population’’
who could better benefit from sLND and experience
successful cure via such an aggressive approach. Thus,
among patients with BCR after primary treatment for
whom where whole-body magnetic resonance imaging
excludes bone disease, are we ready for sLND even if
imaging findings are negative? Perhaps the minimally
invasive robotic approach could accelerate adoption of
this strategy in the future.
Conflicts of interest: The authors have nothing to disclose.
References
[1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9] Fodor A, Berardi G, Fiorino C, et al. Toxicity and efficacy of salvage
11C-choline PET/CT-guided radiation therapy in patients with
prostate cancer lymph nodal recurrence. BJU Int. In press.
[10]
.
E U R O P E A N U R O L O G Y 7 2 ( 2 0 1 7 ) 4 3 9 – 4 4 1 440