Prostate cancer is the second most commonly diagnosed cancer in men and the fifth leading cause of cancer-related deaths worldwide [1]. Recently, the incidence of high-risk prostate cancer has been increasing, accounting for 23% of all biopsy-confirmed prostate cancer cases. Furthermore, the National Comprehensive Cancer Network (NCCN) risk stratification system stratified 60% of high-risk prostate cancer cases into the very high-risk (VHR) category [2,3]. As part of a multidisciplinary therapeutic approach for VHR prostate cancer, robot-assisted radical prostatectomy (RARP) has become increasingly prevalent, along with advancements in imaging modalities, surgical instruments, techniques, and anatomical understanding [4,5]. For example, a prostate magnetic resonance imaging (MRI) plays a crucial role in the surgical planning by providing detailed information on tumor size, precise location, potential extracapsular extension (ECE), and seminal vesicle invasion [6,7].

Complete local cancer control without compromising functional outcomes is challenging owing to its aggressive oncological profile and higher rate of positive surgical margin (PSM) [5]. More aggressive tumors require wider dissection away from the prostate gland. However, wider resection can risk damaging critical anatomical structures, particularly the periurethral structures responsible for continence, such as the puboperineal muscles and sphincters, potentially resulting in poorer post-prostatectomy continence. In addition to wide resection, neoadjuvant hormonal therapy (NHT) increases the probability of complete tumor resection, enhancing local cancer control and likely yielding improved postoperative outcomes [8]. Randomized controlled trials demonstrated that androgen-receptor signaling inhibitor (ARSI)-based NHT reduced tumor size, incidence of biochemical recurrence (BCR), and metastasis-free survival [9]. In contrast, vintage NHT, which consists of luteinizing hormone-releasing hormone (LH-RH) agonists or antagonists, is not recommended under current guidelines, except in a clinical trial setting, because of its lack of benefit in BCR or cancer-specific survival [[10], [11], [12]]. Nonetheless, vintage NHT has still been used in Japanese clinical practice, where ARSI-based NHT is not currently covered by public medical insurance [13].

Further, prostate-specific membrane antigen positron emission tomography (PSMA PET), recommended by international guidelines, is not yet available in Japan, necessitating reliance on conventional imaging modalities such as prostate MRI, computed tomography (CT), and bone scintigraphy for preoperative staging [[11], [12], [13]]. The Japanese public medical insurance also does not cover PSMA PET. Compared to these modalities, PSMA PET offers superior sensitivity and specificity in detecting subclinical nodal and bone metastases, significantly enhancing staging accuracy and advancing the multidisciplinary management of VHR prostate cancer [14].

In our hospital, conventional imaging modalities are utilized to evaluate local cancer advancement, and traditionally, vintage NHT was utilized for VHR prostate cancer. Although this approach deviates from established international guidelines owing to constraints imposed by the Japanese public medical insurance system [[11], [12], [13]], we believe that evaluating our wide resection techniques during RARP for VHR prostate cancer, along with providing detailed pathological insights into features associated with wide resection, will be valuable for other surgeons. Such information can aid in accurately identifying resection margins and reducing the rate of PSMs, thereby enhancing local cancer control as part of a multidisciplinary therapeutic strategy for VHR disease. Notably, this is particularly beneficial given the limited literature addressing the association between PSMs and the pathological features of VHR prostate cancer.

In this study, we aimed to assess the effectiveness of our wide resection techniques designed to achieve complete tumor removal while preserving postoperative continence by analyzing the surgical and pathological outcomes of conventional RARP following vintage NHT for VHR prostate cancer. Our primary focus was on the technique's efficacy in reducing the rate of PSMs. Additionally, we examined the pathological characteristics of VHR prostate cancer, with particular emphasis on its patterns of local invasion, to refine and optimize surgical strategies that further minimize the risk of PSMs in this challenging cohort.