Oncologic and Functional Outcomes of Salvage Robot-Assisted Radical Prostatectomy: Report of the First 10 Cases

Comments 1: 

Introduction: The manuscript provides data related to prostate cancer in 2020. I recommend including more recent data to reflect the current trends and statistics.

Response 1: 

Thank you for the comment.  We added the following text in the revised manuscript. In page 1 on lines 34-35. "In the USA, 288,300 new cases of prostate cancer were newly diagnosed in 2023 [2]."

Accordingly, we added the reference below and corrected the numbers of the references after this.

[2] Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA Cancer J Clin. 2023;73:17–48. doi: 10.3322/caac.21763.

Comments 2: 

Table 4: While the table on page 5 is well formatted, there is some confusion when reading the entries for "prior" and "treatment" on page 4. Please consider reformatting this section for better clarity, if possible. If this issue is due to the formatting of the journal, it can be addressed during the publication process.

Response 2:  We omitted the line break after the word “Prior” and the words “prior” and “treatment” are now in the same line. Additionally, we added the phrase (initial radiotherapy or focal therapy) below the phrase “Prior treatment” in Table 4 in page5.

Comments 3: 

Lines 131-133: The phrase "........ actually developed biochemical recurrence" should emphasize that although your study observed this outcome, it is equally important to note that your follow-up period is relatively short. Highlighting this point will add depth to the discussion of your findings.

Response 3: We added the following phrase to the text (page 6, lines 144-145) ", although the follow-up period was relatively short."

Comments 1: 

The manuscript titled "Oncologic and Functional Outcomes of Salvage Robot-Assisted Radical Prostatectomy: Report of the First 10 Cases" is well-written and addresses a highly relevant topic in urologic oncology. The focus on salvage prostatectomy in patients who have undergone various prior treatments, including radiation therapy, is particularly pertinent given the increasing number of such cases and the limited data available in the current literature. While the sample size of 10 cases is small, the study's findings contribute valuable preliminary data to an area where robust evidence is sparse. This makes the manuscript a worthwhile addition to the field, despite the limited cohort. However, I think it would be best for the authors to incorporate and discuss the findings of the recent narrative review (PMID: 38701186) within their manuscript. This will provide a more comprehensive context and highlight the current state of research on this topic. Given these considerations, I believe a major revision is required to enhance the manuscript's depth and ensure it meets the high standards expected for publication.

We appreciate the comment and advice. We added the following text in the revised manuscript. In page 5 on lines 131-137.

“However, it should be noted that previous studies have observed rectal injury as a major complication after sRARP [13,14,18]. Thakker et al. provided a valuable suggestion in such a situation [21]. The pelvis should be filled with saline, and air should be instilled in the rectum through a rectal probe or a catheter to see any evident air bubbles [21]. In such cases, consultation with the general surgery regarding colostomy or a two layered repair should be considered [21].

Comments 1: 

Salvage RARP is a controversial issue still, however, since more prostate directed radiotherapy and focal therapy is being performed this approach will get more and more attention. The authors describe only a very small series of patients that have undergone different initial treatments, which make interpretation difficult. There have been several publications on salvage RARP even comparing the series with initial RARP and these have not been cited.

In case of suspected recurrence a proper diagnosis should be performed (mpMRI and biopsies and dissemination investigation) and this has not been done in this small series.

Response 1: Publication regarding the comparison between sRARP and standard RARP is already referenced in table 4 (in page 4-5). However, the authors considered that it would be important to show the readers about the context of this study and therefore added some sentences in pages 5-6, lines 137-141.

“Nathan et al. compared oncologic and functional outcomes of sRARP with those of standard RARP [18]. The surgical outcomes of sRARP versus standard RARP were as follows; Grade III-IV Clavien-Dindo complication rates: 1.5% vs. 0% (p = 0.310), pad free continence rates: 78.8% vs. 84.3% at 2years (p = 0.337), 94.8% vs. 76.3% (p < 0.001) [18].”

As the reviewer suggested (In case of suspected recurrence a proper diagnosis should be performed (mpMRI and biopsies and dissemination investigation) and this has not been done in this small series.), we added this context in the text in page6 lines 145-147.

“All cases showed remnant cancer at the time of sRARP, but it should be noted that all cases should have undergone prostate biopsy prior to sRARP.”