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Page 2 of 8 De Luca et al. Mini-invasive Surg 2022;6:13 https://dx.doi.org/10.20517/2574-1225.2021.127

at 12 months follow-up was 0.2 ng/mL (SD 0.01), with no Biochemical Failure (BCF) recorded.

Conclusion: sRARP with TAR technique is a safe and feasible procedure in patients with BCF after primary HIFU.
No major complications were recorded, with good oncological and functional results after one year follow up.

Keywords: Prostate cancer, focal therapy, HIFU, safety, salvage therapy, magnetic resonance imaging, PSMA-
PET/CT

INTRODUCTION
The prostate cancer (PCa) screening strategies, mainly based on serum prostate-specific antigen (PSA)
levels evaluation, currently result in an overdiagnosis of low-/intermediate-grade organ-confined
neoplasms . Some of these patients (i.e., low risk PCa with life expectancy > 10 years) can be safely treated
[1,2]
[3]
with active surveillance . On the other hand, a number of patients with intermediate risk PCa are eligible
for active radical treatment [i.e., radical prostatectomy (RP) or radiotherapy] which may be classified as
“overtreatment” (mostly in case of low percentage of Gleason pattern 4, ≤ 10%), considering the potential
side effects .
[4-6]
This is the reason why urologists have started to offer a more tailored treatment in men with localized low
and early intermediate grade PCa. The aim is to minimize the impact on patient’s quality of life from
primary surgery or radiotherapy while maintaining the best oncological outcomes . Non-surgical focal
[7]
therapies for PCa perfectly fit in this scenario since they are characterized by limited systemic effects and
low chance of damaging the surrounding anatomical structures (i.e., urethra, sphincter, neurovascular
bundles, and bladder neck) [8-10] . On the other hand, considering that PCa is often multi-focal, a proportion
of patients will develop local recurrent disease.

High-intensity focused ultrasound (HIFU) is one of the ablative modalities that have been approved for
clinical use within prospective registry studies, although it remains experimental according to international
[3]
guidelines . The percentage of local recurrence after HIFU is quite common mostly in case of partial
compared to total ablation; 32%-40% experienced recurrence requiring further treatment within 5 years
after partial HIFU ablation and 54% by 8 years in two large, multicentre series [9,11] . Furthermore, the rate of
recurrence post-HIFU may increase with longer follow-up.

Despite no consensus on the optimal management of recurrent PCa after primary HIFU therapy, up to now
salvage prostatectomy (sRP) is reserved for only very few patients because of technical challenges and
frequent post-operative complications. In particular, there are very limited published data on functional and
oncological outcomes for salvage robot assisted RP (sRARP) after HIFU [12-15] .

The primary aim of the present study was therefore to describe our surgical technique of sRARP
characterizing the perioperative, functional, and oncological outcomes during the first year follow up. The
secondary aim was to present a review of the current literature about this topic.

METHODS
Study population
We retrospectively evaluated our prospectively maintained RARP database and extracted patients who
underwent sRARP with total anatomical reconstruction (TAR) technique for biochemical recurrence after
primary HIFU from January 2015 to June 2020. Inclusion criteria were preoperative diagnosis of recurrent