Salvage prostatectomy in patients who have failed radiation therapy or cryotherapy as primary treatment for prostate cancer

doi:10.1016/j.urology.2003.09.001

Urology

Volume 62, Supplement, 29 December 2003, Pages 69-78

https://doi.org/10.1016/j.urology.2003.09.001 Get rights and content

Abstract

Asymptomatic prostate-specific antigen (PSA) recurrence after radiation therapy for prostate carcinoma poses a diagnostic and therapeutic dilemma for clinicians. Patients with locally recurrent disease can consider treatment options of salvage surgery, cryotherapy, watchful waiting, or androgen deprivation. Of these options, only salvage surgery has been shown to result in long-term disease-free survival for selected patients. However, salvage surgery is associated with significant morbidity, including urinary incontinence and rectal injuries. Ideally, salvage surgery outcomes can be optimized with careful patient selection according to clinical stage, serum PSA levels before radiation and surgery, the medical condition of the patient, and clear expectations of the physician and patient. Among patients with locally recurrent disease, those with localized prostate carcinoma amenable to radical prostatectomy before radiation or cryotherapy would be the most suitable candidates for salvage surgery.

Section snippets

Biochemical recurrence after radiation/cryotherapy

After contemporary local therapy for prostate cancer, recurrence is most commonly an increasing PSA level in an otherwise healthy patient without evidence of clinical disease or palpable recurrence.7, 9, 30 Nonextirpative local therapies, including radiation, brachytherapy, and cryotherapy, have comparable local tissue effects, and the diagnosis and management of recurrence after these therapies is similar. The trajectory of serum PSA levels after radiation therapy decreases more gradually and

Local recurrence of prostate carcinoma

To make the diagnosis of local recurrence, positive results from a prostate biopsy for prostate cancer is mandatory. Biochemical recurrence, a new nodule, or changing findings on digital rectal examination should be evaluated with transrectal ultrasound–guided prostate biopsy. The role of postradiation biopsies for monitoring early radiation treatment response has been subject to debate on timing, interpretation, and usefulness.47, 56, 57

Interpretation of postradiation prostate needle biopsies

Selection of ideal candidates for salvage surgery

The selection of appropriate patients who would benefit from salvage surgery is a daunting task. Surgery should only be considered in men with an isolated, biopsy-proven local tumor recurrence. Patients should be young and healthy and have minimal medical comorbidities that would limit life expectancy to <10 years. Despite the low sensitivity, results from a bone scan, chest radiograph, and CT scan of abdomen and pelvis should be negative for systemic disease or pelvic lymphadenopathy.

Role of hormonal therapy

Recent studies suggest that patients with locally advanced prostate cancer undergoing radiation therapy benefit from adjuvant hormone therapy.73, 74 To our knowledge, no data exist on the relative efficacy of radiotherapy with or without androgen deprivation therapy for men with clinically localized disease. However, many patients undergoing radiation therapy for clinical stage T1 or T2 prostate cancer receive some form of androgen deprivation therapy, which can be a confounding factor during

Salvage procedures: surgical technique

A successful outcome after salvage surgery requires careful patient selection, surgeon experience, and preoperative counseling of patients, including a frank discussion of the significant potential for perioperative morbidity and postoperative incontinence and impotence. The possibility of rectal injury at the time of operation and need for temporary colostomy should be raised. A full mechanical and intraluminal antibiotic bowel preparation is recommended. Additionally, all patients should be

Salvage cystoprostatectomy

Our preference is to perform radical prostatectomy for clinically localized radiorecurrent prostate cancer when possible. Nevertheless, preoperative factors and intraoperative findings dictate the decision to perform cystoprostatectomy with urinary diversion. Patients with a contracted bladder, urinary incontinence, hemorrhagic cystitis, or concomitant bladder cancer should undergo cystoprostatectomy and expect good palliation of symptoms.64

In extensive local recurrence, benefits of salvage

Salvage surgery results

During the PSA era, the stage migration seen in men presenting with an initial diagnosis of prostate cancer was mirrored in men presenting for salvage surgery for recurrence after local therapy. Preoperative staging for nearly all patients in early reports consisted of palpable, clinical local recurrence,14, 15, 16, 17, 18, 87, 88 whereas recent series reported a growing number of patients with recurrence detected after biochemical failure.24, 25, 26, 27, 28 After contemporary salvage surgery,

Complications

Salvage surgery is associated with a significantly higher rate of complications than in de novo radical prostatectomy because of fibrosis and loss of anatomic tissue planes (Table III).14, 15, 16, 17, 18, 19, 20, 24, 25, 26, 27, 28, 76, 87, 88, 90 In contemporary series, perioperative parameters, such as mean estimated blood loss and length of stay, have improved, and they approach outcomes reported for primary radical prostatectomy.26, 28 The rate of rectal injuries ranges from 0% to 35%,

Conclusion

With vigilant PSA screening, recurrent disease after definitive local therapy for prostate cancer is commonly an asymptomatic increasing PSA level rather than clinically palpable disease. A growing subset of young healthy patients who were good candidates for primary prostatectomy will present for salvage therapy after radiation therapy with PSA-only recurrence. Careful patient selection and discussion of treatment options with suitable candidates can identify patients who would most benefit