Oncological and perioperative outcomes following salvage robotic radical prostatectomy after radiation versus focal therapy: a multicenter analysis of 441 patients

BACKGROUND: Salvage robotic radical prostatectomy (sRRP) represents a definitive local treatment option for recurrent prostate cancer following nonsurgical primary therapy. However, the impact of prior treatment modality on oncological outcomes and perioperative morbidity remains incompletely defined. OBJECTIVE: To evaluate oncological outcomes and perioperative complications following sRRP and to assess the influence of prior radiation therapy (RT) versus focal therapy (FT) using a multicenter retrospective cohort. DESIGN: We conducted a multicenter retrospective analysis of 441 patients who underwent salvage robotic radical prostatectomy (sRRP) after prior radiation therapy or focal therapy across participating institutions to reflect real-world clinical scenarios. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcome was recurrence-free survival (RFS). Secondary outcomes included cancer-specific survival (CSS), overall survival (OS), and 90-day postoperative complications. Kaplan-Meier analysis and multivariable Cox regression were used for survival outcomes, while logistic regression was used to identify predictors of complications. RESULTS: Patients in the RT group exhibited more adverse baseline pathological features, including higher rates of advanced stage and nodal disease. FT was associated with improved RFS, with early and sustained separation of survival curves. In contrast, CSS and OS were comparable between groups. On multivariable analysis, node-positive disease was the strongest predictor of adverse oncological outcomes, while treatment modality was not independently associated with CSS or OS. The overall complication rate was 27%, with significantly higher rates observed in the RT group compared to FT (31% vs 18%, p = 0.004). Prior RT was identified as the strongest independent predictor of postoperative morbidity. CONCLUSIONS: Prior treatment modality influences recurrence patterns and perioperative morbidity following sRRP, while long-term survival outcomes are primarily driven by tumor biology. FT may offer a more favorable perioperative profile, whereas RT is associated with increased surgical complexity and complications.