May Outcomes of Robotic Radical Prostatectomy Performed After an Initial Surveillance Strategy Differ from Those from Immediate Surgery? A Propensity Score-Matched Analysis on 362 Patients Undergoing Surgery at a Referral Center.

Introduction: Active surveillance (AS) is a treatment strategy for low-risk prostate cancer (PCa) patients, with extended indication to some intermediate-risk PCa. However, active treatment is necessary in case of disease progression and robotic radical prostatectomy (RALP) is one of the treatment modalities. The aim of the study is to compare outcomes of a delayed RALP after an initial heterogeneous surveillance strategy with those of immediate RALP in a single referral center. Methods: Data from patients who underwent RALP after initial assumed "active surveillance" (referred from different institutions and backgrounds) were compared to those of patients who underwent an immediate RALP after propensity score (PS) matching. The PS analysis was performed matching ISUP score at the time of entering surveillance with ISUP at RALP for the control group; other matching covariates at the time of surgery were considered (including age, prostate-specific antigen, body mass index, prostate size, cT, pre-op Sexual Health Inventory for Men, etc.). Perioperative, functional, and oncological outcomes were compared between groups. Results: Three hundred sixty-two RALP patients were included (181 after surveillance and 181 immediate RALP). Patients after surveillance had a worse pT and ISUP score ( p  < 0.001); LVI and EPE were higher in the surveilled group (13% vs. 5%, p  = 0.001; 38% vs. 22%, p  = 0.001), without significant difference in positive surgical margin. At a median follow-up of 24 months, the risk of biochemical recurrence (BCR) was significantly higher for delayed RALP (hazard ratio: 4.0; 95% confidence interval: 1.4-12; p  = 0.013), whereas potency and continence rate did not differ significantly. Conclusions: At a referral center receiving patients from diverse backgrounds, outcomes of RALP after heterogeneous surveillance strategies are variable and less predictable, maybe attributable to different protocols and surgical planning. The higher BCR rate in a high-risk surveilled cohort may suggest an increased burden of cancer-related care for RALP patients after surveillance.