Extrafascial robot-assisted laparoscopic radical prostatectomy (EF-RALP) in locally advanced prostate cancer.

INTRODUCTION: Up to 26.5% of new dewly diagnosed prostate cancers (PCa) are locally advanced (LA). Although traditionally discouraged in this setting, radical prostatectomy (RP) lowers the risk of metastatic progression and cancer-specific death. We report a review of the available evidences and describe our surgical technique of Extrafascial robot-assisted RP.

EVIDENCE ACQUISITION: The PubMed/Medline database was searched for "prostate cancer", "high-risk", "locally advanced", "prostatectomy". Duplicates and expert opinion papers were removed.

EVIDENCE SYNTHESIS: RP is an option in selected patients with LA-PCa and >10 years life expectancy. Five, 10 and 15 years after open RP, disease free survival rates were 85%, 73% and 67%. At the same time-points, cancer specific survival and overall survival were 95%, 90%, 79% and 90%, 76%, 53%, respectively. Post-operative potency was achieved by 25% of the patients while 79% were continent. Robotic prostatectomy provides comparable cancer control outcomes, but it is associated with a lower transfusion rate and a shorter hospitalization time. The concept of "extrafascial prostatectomy" was introduced in 2000 by Villers: this surgical approach reduces the incidence of mid- and postero-lateral positive margins (28% vs 51%, when compared to intrafascial; p = 0.08), expecially in pT3 cancers, but markedly affects potency.

CONCLUSIONS: Robot-assisted RP is an option in patients with LA-PCa. Removing the prostate gland and the seminal vesicles still contained inside their aponeurotic covering, minimize the risk of positive surgical margins and clinical recurrence.