Robotic assisted radical prostatectomy improves biochemical recurrence-free survival: The PROCA-life study

Robotic-assisted laparoscopic prostatectomy (RALP) is the preferred surgical technique compared to radical retropubic prostatectomy (RRP), but reports have been inconsistent on the effect of RALP on positive surgical margins (PSM) and biochemical recurrence (BCR). This study includes 420 men who participated in the population-based Tromsø study and PROCA-life study, diagnosed with prostate cancer (PCa) during 1995–2022, and treated with curative surgery. Overall, 171 PCa patients underwent open surgery with RRP, performed 1995–2012, and 249 PCa patients underwent RALP, performed 2012–2022. Preoperative and postoperative clinical characteristics were recorded. Multivariable Cox regression models presented with hazard ratios (HR) were used to study the association between surgical technique, preoperative and postoperative characteristics, and BCR. Overall, 72 patients (42.1%) in the RRP group, and 47 patients (18.9%) in the RALP group had BCR. Median time from surgery to BCR was 26.9 (IQR 10.2–58.0) months and 24.5 (IQR 15.4–46.9) months, respectively. PSM were three times more frequent in the RRP group compared to the RALP group (42.9% vs. 14.0%). Five-year BCR-free survival in the RRP group was 67% (95% CI 59–74), in the RALP group 81% (95% CI 75–86). The RALP procedure independently decreased the risk of BCR compared to RRP (HR 0.52; 95% CI 0.34–0.80, p = 0.003). PCa patients who had PSM had a doubled risk of BCR compared with patients with negative surgical margins (HR 2.00; 95% CI 1.31–3.05, p < 0.001). Patients with ISUP grade 3–5 (vs. grade 1) had an increased risk of BCR, highest with ISUP 4/5 (HR 3.44, 95% CI 1.79–6.61, p < 0.001). Implementation of RALP reduced the risk of biochemical recurrence compared to RRP, partly explained by the markedly lower PSM rate after RALP.