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De Luca et al. Mini-invasive Surg 2022;6:13 https://dx.doi.org/10.20517/2574-1225.2021.127 Page 3 of 8

PCa with positive PSMA positron emission tomography scan and/or suspect area at prostate
multiparametric magnetic resonance imaging (mpMRI). The radiologic suspect criteria for prostate lesions
[16]
were defined a posteriori, in accordance with the Prostate Imaging Recurrence Reporting (PI-RR) score .
All the patients enrolled in the study had no contraindications in performing RARP (i.e., good performance
status, no previous major abdominal surgery, and no contraindication in maintenance of Trendelemburg
position).

Biochemical recurrence was defined, in accordance with ASTRO-Phoenix criteria, as a PSA rise equal or
[17]
greater than 2 ng/mL above the PSA nadir, regardless of ongoing androgen deprivation therapy . Patients
with a follow up after salvage RARP less than 1 year were excluded.

Surgical technique
All the surgical interventions were performed by a single expert laparoscopic surgeon (F.P.) with great
experience in robot-assisted PCa surgery. All the procedures were performed following the TAR technique
which has been previously described and proven to be safe and feasible in different scenarios [18-20] . Briefly,
after the demolition phase of the radical prostatectomy, a three-layer posterior reconstruction and a two-
layer anterior reconstruction were performed in addition to the urethra-vesical anastomosis. As shown in
Figure 1, the posterior reconstruction involved the Denonvilliers’ fascia and the median raphe, then the
retrotrigonal fascia and the median raphe, and lastly the bladder neck and the posterior aspect of the
rhabdosphincter. The anterior reconstruction involved the muscular fibres of the bladder and the peri-
urethral tissue, after a second layer of suture is performed between the vesical apron and the portion of the
endopelvic fascia that covers the dorsal vein complex while involving the pubo-prostatic ligaments. An
extended lymph node dissection was performed in all the cases including iliac, obturator, and presacral
lymph node removal. Nerve-sparing was performed in very few cases, in accordance with preoperative local
imaging staging and preoperative patient’s erectile function.

Data collection and statistical analysis
Demographics were collected. In particular, pre-HIFU Gleason score, and D’Amico risk classification were
evaluated, along with pre sRARP PSA levels and PI-RR score of mpMRI findings. PSA levels at 1, 3, 6, and
12 months after the intervention were registered.

Clavien Dindo classification system was used to classify postoperative complications up to 12 months.
Baseline International Prostatic Symptoms Score, quality of life, and International Index of Erectile
Function (IIEF-5) were collected and re-evaluated at 1, 3, 6 and 12 months after the procedure. Continuous
variables were described using mean and standard deviation, and discrete variables were described using
median and interquartile ranges. Frequency tables were used to summarize categorical variables.

RESULTS
From January 2015 to June 2020, 11 patients underwent post-HIFU sRARP with TAR technique at our
institution. Demographics as well as preoperative and postoperative oncological and functional data are
reported in Table 1.

Of these 11 patients, 8 had previously undergone total gland ablation while 3 had partial gland ablation for
low-intermediate risk PCa. The mean time interval between HIFU and sRARP was 32.3 months (SD 11.4
months). Mean pre sRARP PSA was 3.6 ng/mL (SD 2 ng/mL) and mean prostate volume was 37.9 mL (SD
13.3 mL).