Robot-assisted radical prostatectomy reduces biochemical recurrence risk and improves urinary continence recovery compared with laparoscopic approach in high-risk localized prostate cancer after neoadjuvant therapy: a real-world propensity score-matched analysis.

This retrospective study compared the oncological and functional outcomes of robot-assisted radical prostatectomy (RARP) versus laparoscopic radical prostatectomy (LRP) in 523 patients with high-risk localized prostate cancer (HR-LPC) receiving neoadjuvant therapy (NAT). After 1:1 propensity score matching (PSM), 218 patients per group were included. Multivariate Cox regression confirmed that RARP was independently associated with a significantly lower biochemical recurrence (BCR) risk compared with LRP (after PSM: HR=0.626, 95% CI 0.471-0.833, P=0.001), a finding that remained robust across all sensitivity analyses. Subgroup analyses identified significant BCR protection by RARP in patients with preoperative PSA ≥20 ng/mL (P=0.001), pathological T stage pT2-pT3a (P=0.002), biopsy ISUP grade 4 (P=0.005), negative lymph nodes (P<0.001), ADT monotherapy (P=0.007), and age ≥65 years (P=0.002), with no significant heterogeneity across subgroups (all P-interaction >0.05). RARP also demonstrated perioperative advantages over LRP, including less intraoperative blood loss (median 239.5 vs. 399.5 mL, P<0.001), lower transfusion rate (4.59% vs. 12.39%, P=0.003), and shorter hospital stay (median 7 vs. 9 days, P<0.001), while pathological outcomes were comparable between groups (all P>0.05). Regarding functional recovery, RARP achieved significantly higher urinary continence rates at postoperative months 1 (33.5% vs. 21.1%, P=0.005), 3 (53.2% vs. 38.5%, P=0.003), 6 (74.8% vs. 60.6%, P=0.002), and 12 (84.9% vs. 73.9%, P=0.006), with a median continence recovery time of 3 months versus 6 months in the LRP group (P<0.001). These findings suggest that RARP offers meaningful oncological and functional advantages over LRP in HR-LPC patients undergoing NAT.