Robot‐Assisted Salvage Prostatectomy: External Validation of the EAU Selection Criteria and Identification of the Optimal Candidate: A Junior ERUS/YAU Collaborative Study

Background EAU guidelines recommend salvage radical prostatectomy (sRP) only in highly selected patients with recurrent prostate cancer in experienced centers. Methods The Junior ERUS/Young Academic Urologist Working Group on Robot‐Assisted Surgery conducted a multicentric project to investigate biochemical recurrence‐free (BCR), metastases‐free (MFS), and overall survival (OS) outcomes in robotic sRP patients stratified according to EAU criteria. Results Of 180 patients, 49% fulfilled EAU criteria. Patients not fulfilling EAU criteria more frequently underwent focal therapy as primary treatment (53% vs. 33%) and exhibited significantly higher rates of pT3–4 (70% vs. 48%), positive surgical margins (48% vs. 24%), and pathological Gleason score 8–10 (72% vs. 48%, all p < 0.01), with no differences in postoperative complications. Rates of PSA persistence were significantly higher in patients not fulfilling EAU criteria (16% vs. 0%, p < 0.001). Regarding BCR, patients not fulfilling EAU criteria harbored significantly worse BCR‐free survival (hazard ratio (HR): 1.96, p = 0.046) with 24‐ and 48‐month BCR‐free survival rates of 81.7% and 73.9% vs. 65.0% and 58.5% for patients fulfilling EAU criteria. After multivariable adjustment, patients not fulfilling EAU criteria harbored higher risk of BCR (HR: 2.94, p = 0.045). Regarding MFS and OS outcomes, no significant differences were observed in the comparison between both groups. Incorporating presalvage surgery features into a new classification yielded better discrimination for BCR analysis, but were comparable to EAU criteria for MFS and OS outcomes. Conclusions The majority of patients do not fulfill EAU criteria, and even more so after focal therapy. These patients harbor worse BCR rates after robotic sRP. However, within our short‐term follow‐up, no differences in MFS and OS were observed.