Background:Locally advanced prostate cancer (PCa) is commonly treated with multimodal therapy; however, long-term outcomes of surgery alone are poorly defined. We investigated the potential and limitations of robot-assisted radical prostatectomy (RARP) as primary treatment without perioperative systemic therapy in patients with locally advanced PCa.Methods:We retrospectively analyzed 258 patients who underwent RARP with extended pelvic lymph node dissection between 2012 and 2022 with locally advanced PCa, defined as present if at least one of the following was met: clinical stage cT3b–T4; primary Gleason pattern 5; >4 biopsy cores with Grade Group 4 or 5; or more than one NCCN high-risk characteristic. Patients who received neoadjuvant or adjuvant therapy were excluded. Endpoints included biochemical recurrence-free survival, metastasis-free survival, cancer-specific survival, and predictors of persistent PSA.Results:Median follow-up was 60.6 months. Pathological stage ≥ pT3a occurred in 63.6% and nodal involvement (pN1) in 27.1%. Five-year BRFS, MFS, and CSS were 36.6%, 88.9%, and 98.3%, respectively. Persistent PSA occurred in 21.3%. Preoperative predictors included PSA > 40 ng/mL, clinical stage ≥ cT3a, and >4 biopsy cores with a Gleason score of 8–10; patients with ≥2 features had significantly poorer BRFS and MFS. Postoperative predictors of recurrence were pathological stage, lymphovascular invasion, and nodal involvement.Conclusions:RARP alone provided durable long-term cancer control in selected men with locally advanced PCa, whereas patients with multiple adverse features were unlikely to be cured with surgery alone. Careful risk stratification may identify candidates for surgical monotherapy and help avoid overtreatment, while others may benefit from multimodal therapy.
背景：局部进展性前列腺癌通常采用多模式治疗，但单纯手术的长期疗效尚不明确。本研究旨在探讨机器人辅助根治性前列腺切除术作为局部进展性前列腺癌患者主要治疗手段（不联合围手术期全身治疗）的潜力与局限性。 方法：回顾性分析2012年至2022年间接受RARP联合扩大盆腔淋巴结清扫术的258例局部进展性前列腺癌患者。局部进展性定义为至少符合以下一项标准：临床分期cT3b–T4；主要Gleason评分5级；≥4个活检核心显示分级分组4或5级；或具备多个NCCN高危特征。排除接受新辅助或辅助治疗的患者。研究终点包括无生化复发生存期、无转移生存期、癌症特异性生存期及持续PSA的预测因素。 结果：中位随访时间60.6个月。63.6%患者病理分期≥pT3a，27.1%存在淋巴结转移（pN1）。5年无生化复发生存率、无转移生存率和癌症特异性生存率分别为36.6%、88.9%和98.3%。21.3%患者出现持续PSA。术前预测因素包括PSA>40 ng/mL、临床分期≥cT3a及>4个活检核心Gleason评分8-10分；具备≥2项特征的患者无生化复发生存期和无转移生存期显著缩短。术后复发预测因素包括病理分期、淋巴血管侵犯和淋巴结转移。 结论：对于经选择的局部进展性前列腺癌患者，单纯RARP可提供持久的长期癌症控制，而具有多项不良特征的患者仅通过手术难以治愈。精细的风险分层有助于筛选适合单一手术治疗的候选者，避免过度治疗，同时识别可能受益于多模式治疗的患者群体。
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