Robotic-assisted radical prostatectomy in the elderly patient – a study of functional, surgical, and oncological outcomes in an Australian cohort

Background: Curative surgery for prostate cancer is uncommonly offered to patients aged ≥75, balancing functional outcomes against survival benefit. The increased adoption of robotic-assisted radical prostatectomy (RARP) and improved overall life expectancy challenges this paradigm. The objective of this study was to compare functional outcomes between elderly and younger patients following RARP. Methods: Retrospective review of prospective multicentre database including all RARP patients between October 2016 to December 2023. Patients were divided into cohorts based on age; elderly (≥75 years) and younger (<75 years). Outcomes included baseline demographics (body mass index [BMI], American Society of Anaesthesiologists [ASA] classification, prostate specific antigen [PSA], Gleason score), surgical (technique, complications, length of stay), pathological (histopathology, margins, PSA) and functional (incontinence, International Prostate Symptom Score [IPSS], International Index of Erectile Function [IIEF-5], Expanded Prostate Index Composite [EPIC]) outcomes. The primary endpoint was continence at 1-year (number of pads/day). Chi-squared and t-tests were used and p-values <0.05 considered statistically significant. Results: A total of 397 patients were included (<75;n=332, ≥75;n=65). No statistically significant differences were detected in continence in ≥75 (<75; 0.73 [0.59-0.87], ≥75;0.66 [0.37-0.95] mean pads/24hr, p=0.8), despite significantly lower nerve preservation and bladder-neck spare rates (<75;37.3%, ≥75;21.5%). IIEF-5 scores were worse in the ≥75 group (1.60±1.17 vs 5.73±6.93 p<0.001), however there were no significant differences in IPSS. Patient in the elderly cohort had more severe disease (67.7% T3, ≥75 vs 47.3%, <75, p<0.05) Rates of positive surgical margins (28.3% vs 30.8% [≥75]) and PSA recurrence (25% vs 23% [≥75]) were similar. Complication rates were low in both groups with no significant differences (3% vs 6.6% [≥75]) and were of lower severity in the ≥75 group. Conclusion: RARP in carefully selected elderly patients does not increase risk of urinary incontinence and should not be disregarded in an aging population with higher overall life expectancy.