Laparoscopic Versus Robot-Assisted Radical Prostatectomy: Outcomes for pT3-4N0-1M0 Prostate Cancer

Technical Summary: Laparoscopic Versus Robot-Assisted Radical Prostatectomy for pT3-4N0-1M0 Prostate Cancer

Problem Statement
Prostate cancer (PCa) remains a leading cause of cancer-related morbidity and mortality globally. Locally advanced (pT3-4) or node-positive (N1) disease presents significant therapeutic challenges, often requiring multimodal management including radical prostatectomy (RP), pelvic lymph node dissection (PLND), and androgen deprivation therapy (ADT). While Laparoscopic Radical Prostatectomy (LRP) is widely adopted for its clinical merits, Robot-Assisted Radical Prostatectomy (RARP) offers enhanced visualization and dexterity. However, comparative outcomes between LRP and RARP specifically within the high-risk pT3-4N0-1M0 setting remain inadequately studied, with most existing literature focusing on localized disease. This study aims to fill that gap by comparing the efficacy and safety of both techniques in this specific high-risk cohort.

Methodology
This retrospective study, conducted at Shenzhen Second People's Hospital between August 2021 and July 2025, enrolled 70 patients with pT3-4N0-1M0 PCa. The cohort was divided into two matched groups: 35 patients undergoing LRP and 35 undergoing RARP.

• Inclusion Criteria: Preoperative PSA > 20 ng/mL, negative findings for lymph node and bone metastasis on preoperative MRI and bone scan, and receipt of PLND during surgery.
• Standardized Protocol: All patients received neoadjuvant goserelin (3 months pre-op) and resumed ADT postoperatively (3 months post-op). All surgeries were performed via a transperitoneal approach by a single primary surgeon. LRP utilized conventional laparoscopy, while RARP utilized the Da Vinci Xi Surgical System. PLND included removal of iliac, obturator, and presacral lymph nodes.
• Follow-up: Patients were followed for 12–60 months. Outcomes assessed included perioperative parameters (operative time, estimated blood loss, complications), pathological outcomes (positive surgical margins, pathologic stage), functional recovery (urinary continence), and oncological outcomes (biochemical recurrence).
• Statistical Analysis: Continuous variables were analyzed using Student's t-test or Mann-Whitney U test; categorical variables used the chi-square test. Significance was set at P < 0.05.

Key Results
The study found that while both techniques are effective, RARP demonstrated specific advantages in operative efficiency and early functional recovery, with comparable oncological safety.

• Perioperative Outcomes: The RARP group had a significantly shorter operative time compared to the LRP group (199.3 vs. 248.9 minutes, P < 0.001). There were no statistically significant differences in estimated blood loss (71.1 vs. 80.3 mL), blood transfusion rates (0% in both), postoperative hospital stay, or catheterization duration.
• Pathological Outcomes: Positive surgical margin (PSM) rates were 17.1% for RARP and 28.6% for LRP (P = 0.255), a difference that did not reach statistical significance. Rates of positive lymph nodes and complication rates (both minor and major) were comparable between groups.
• Functional Outcomes (Continence): RARP showed significantly superior urinary continence recovery at 1 month (60.0% vs. 25.7%, P = 0.004), 3 months (82.9% vs. 45.7%, P = 0.001), and 6 months (88.6% vs. 68.6%, P = 0.041). By 12 months, the difference converged, with rates of 94.3% (RARP) and 88.6% (LRP) (P = 0.669).
• Oncological Outcomes: Biochemical recurrence (BCR) occurred in 5.7% of the RARP group and 8.6% of the LRP group, with no significant difference (P = 1.000).

Key Contributions
This study provides direct comparative data for a high-risk patient population (pT3-4N0-1M0) that is underrepresented in existing literature. It establishes that:

1. Both LRP and RARP are safe and effective modalities for high-risk PCa when combined with PLND and immediate ADT.
2. RARP offers a distinct advantage in reducing operative time and accelerating early urinary continence recovery.
3. Despite the numerical trend toward lower PSM rates in the RARP group, the intermediate-term oncological outcomes (BCR) are comparable between the two techniques.

Significance and Claims
The authors conclude that both LRP and RARP are viable options for treating pT3-4N0-1M0 prostate cancer. The study claims that RARP is associated with shorter operative times and earlier continence recovery, while maintaining comparable oncological safety to LRP in the intermediate term. Consequently, the selection of surgical technique should be tailored to individual patient characteristics, surgical proficiency, and institutional capabilities rather than being dictated solely by oncological superiority, as neither technique demonstrated a definitive advantage in cancer control within this study's timeframe.

The authors modestly acknowledge limitations, including the small sample size, the relatively short follow-up period, and the confounding factor of postoperative ADT, which hinders the assessment of the standalone oncological value of each surgical technique. They suggest that larger studies with longer follow-up are necessary to further validate these findings.