Salvage Robot-Assisted Radical Prostatectomy After Radiotherapy or Focal Treatment

The chapter details the current status of Salvage Radical Prostatectomy mainly using the robotic platform and elucidates the technique and outcomes of salvage robot assisted radical prostatectomy (sRARP). It is a complex major surgery for recurrent prostate cancer after failed primary therapy which could be whole gland or focal therapy. Historically, salvage prostatectomy was associated with high morbidity and inferior functional and oncological outcomes compared to a primary radical prostatectomy and thus became a controversial procedure. With the advent of robotic prostatectomy standard dissection techniques have been developed with improved outcomes. Numerous studies have now shown the feasibility of sRARP with oncological and functional outcomes at par with primary surgery following focal primary treatments. ince the spectrum for prostate preserving options have incresed from external beam radiotherapy and brachytherapy to include cryotherapy, irreversible electroporation, augmented laser ablation and high intensity focused ultrasound treatment of the prostate the need for sRARP has increased in parallel. The chapter further describes the indications, preoperative assessments and surgical techniques for sRARP. Various surgical adaptations required based on the primary tretment are described and novel techniques to minimize morbidity are mentioned. A direct comparision of sRARP to salvage radiotherapy following primary focal treatment is discussed. The future demand for sRARP and the surgical expertise and competence is outlined. This chapter aims to outline and describe the current status of salvage robotic assisted radical prostatectomy (sRARP) following various primary treatments. A brief description of the evolution of the surgical technique, early outcomes and existing guidelines are described. Surgical adaptation to the varying anatomy following the different primary treatments are exhaustively described. Feasibility and safety of sRARP with medium term oncological and functional outcomes are quoted. Comparative outcomes of sRARP to primary robot assisted radical prostatectomy (RARP) are discussed along with outcomes of sRARP following focal and whole gland primary treatments. Finally, the chapter ends with the surgical experience and skill required to carry out these challenging procedures and recommendations for training are given.