Theranostic Robot-Assisted Radical Prostatectomy: Things Understood and Not Understood

SIMPLE SUMMARY: Theranostic robot-assisted radical prostatectomy (T-RARP) means adopting RARP as an integration of diagnosis and therapy, and this concept has rarely been discussed. Before the advancement of imaging technologies, the diagnosis of prostate cancer (PCa) needed to rely on systematic biopsies, which had certain limitation of sensitivity and specificity. In our previous reports, even with preoperative benign biopsies, there were still large portions of incidental PCa in specimens of simple prostatectomies. We first introduced the feasibility of T-RARP in 2016 in patients with clinically highly suspected prostate cancer. In 2020, we developed a nomogram to identify the potential groups. With the advantages of imaging technologies, potential groups can be more easily identified, and the concept of T-RARP can be more widely adopted. However, no studies have discussed the benefits of T-RARP in these patients. Herein, we conducted this cohort study to explore the benefits of T-RARP for such patients and topics of T-RARP that are unclear and need to be unveiled in future studies. ABSTRACT: Objective: This study aimed to explore the benefits of theranostic robot-assisted radical prostatectomy (T-RARP) for clinically highly suspicious prostate cancer (PCa) without proven biopsies. Material and Methods: Between February 2016 and December 2020, we included men with clinically highly suspicious PCa in this study. They were assessed to have possible localized PCa without any initial treatments, and were categorized into previous benign biopsies or without biopsies. Furthermore, another group of malignant biopsies with RARP in the same time frame was adopted as the control group. The endpoints were to compare the oncological outcome and functional outcome between malignant biopsies with RARP and T-RARP. p < 0.05 was considered to be significant. Results: We included 164 men with proven malignant biopsies treated with RARP as the control group. For T-RARP, we included 192 men. Among them, 129 were preoperatively benign biopsies, and 63 had no biopsies before T-RARP. Approximately 75% of men in the T-RARP group had malignant pathology in their final reports, and the other 25% had benign pathology. T-RARP provides several oncological advantages, such as a higher initial pathological T stage, lower Gleason grade, and lower odds of positive surgical margins. However, the biochemical recurrence rates were not significantly decreased. From our cohort, T-RARP (odds ratio with 95% confidence interval; erectile recovery: 3.19 (1.84–5.52), p < 0.001; continence recovery: 2.25 (1.46–3.48), p < 0.001) could result in better recovery of functional outcomes than malignant biopsies with RARP. Conclusions: For clinically highly suspicious PCa, T-RARP was able to detect around 75% of PCa cases and preserved their functional outcomes maximally. However, in 25% of men with benign pathology, approximately 6% would have incontinence and 10% would have erectile impairment. This part should be sufficiently informed of the potential groups considering T-RARP.