Functional outcomes after robot-assisted radical prostatectomy in young patients (≤ 55 yrs) with prostate cancer: Is surgery perfect in the best candidates?

INTRODUCTION & OBJECTIVES: The optimal treatment strategy in young patients diagnosed with localized prostate cancer (PCa) should provide cancer control without compromising functional outcomes. The objective of this study was to evaluate the functional outcomes of young patients treated with robot-assisted radical prostatectomy (RARP) at a single tertiary care center in order to evaluate the performance of RARP among the “best candidates”. MATERIAL & METHODS: We identified 297 consecutive patients with clinically localized PCa who were pre-operatively continent and potent (baseline IIEF-EF >21) and aged ≤ 55 yrs. All patients were treated with bilateral nerve sparing RARP between Nov 2007 and Feb 2014. Urinary continence (UC) recovery was defined as no use of pads. Erectile function (EF) recovery was defined as a post-operative IIEF-EF>21. Biochemical recurrence (BCR) was defined as a PSA>0.2 ng/mL and rising. The Kaplan-Meier method was used to assess BCR free-survival and post-operative UC and EF recovery rates. Multivariable Cox-regression models were fitted to assess the predictors of continence and potency recovery after accounting for prostate volume, BMI, and Charlson Comorbidity Index. Pre-operative International Prostate Symptom Score (IPSS) and pre-operative IIEF-EF score were added as covariates when the outcome was UC recovery and EF recover, respectively. All analyses were repeated after stratification according to D’Amico risk group classification. RESULTS: Mean patient age was 51.7 (38-55). Overall, 178 (60%) and 119 (40%) patients had low- and intermediate-risk disease. Preoperative EF was ≥26 in 220 (74.1%) and 21-25 in 77 (25.9%) patients. Positive surgical margins were detected in 25 (8.4%) patients. Five year BCR free-survival rate was 87% in the overall population, being 87 and 88% in low and intermediate risk patients, respectively (p=0.5). UC recovery rates at 1 and 2 years were 84.2 and 92%, respectively. One and 2-year rates of EF recovery were 65.5 and 77.5%, respectively. No significant differences in terms of 2-year UC and EF recovery were observed between low vs. intermediate risk patients (all p>0.6). At multivariable Cox regression analyses, PV and IPSS were significantly associated with the rate of UC recovery after surgery (HR:1.02; 95% CI:1.00-1.04; p=0.01 and HR:0.49; 0.25-0.96; p=0.03, respectively). Pre-operative IIEF-EF represented the only independent predictor of EF recovery after surgery (HR:2.12; 1.16-3.88; p=0.01). CONCLUSIONS: RARP provides excellent oncological and functional outcomes in young patients with low- and intermediate-risk PCa. However, treatment related side effects are not perfect, especially in terms of full EF recovery. There