[Salvage radical prostatectomy].

Abstract

BACKGROUND: Following external beam radiation and interstitial radiation for prostate cancer, between 30% and 50% of the patients experience locoregional recurrence of their cancer. Although radical salvage prostatectomy is a secondary treatment option with curative intent, so far only a few hundred patients (<2%) worldwide have undergone this operation. The subject of this paper is a review of the world literature with reference to the frequency with this operation is performed and the technique, and also the prospects of success and possible complications. PATIENTS AND METHODS: After radiotherapy, approximately 30% of biopsies are positive. Nonetheless, only 536 cases of salvage radical prostatectomy had been reported in the world literature up to 2005. The diagnosis of a local recurrence was always confirmed by rectal punch biopsy, pelvic CT and bone scintigraphy. Salvage radical prostatectomy with or without nerve sparing, with pelvic lymphadenectomy and, in some patients with cystectomy plus urinary diversion was the operative treatment applied. RESULTS: Following secondary treatment after radiotherapy (RT), three parameters have been consistently identified as predictors of local failure: PSA nadir, time to nadir and PSA doubling time; clinical stage and type of first-line treatment are not helpful in predicting failure. The 5-year biochemical relapse-free survival rates are 77%, 71% and 28% for stages pT2, pT3a and pT3b/pN1, respectively. The success rate for salvage radical prostatectomy is thus similar to that for de novo radical prostatectomy for the same stages. In the past salvage radical prostatectomy following radiotherapy had a high complication rate. CONCLUSIONS: A salvage radical prostatectomy with curative intent is a radical prostatectomy following radiotherapy also performed with curative intent. The reasons for the few literature reports of salvage RPX are: (1) oncological misgivings (too long a period of observation of PSA by the radiation oncologist/urologist; (2) misgivings to do with surgical technique, as the operation is technically challenging and involves a high risk of complications, especially incontinence. In recent times the comorbidity rate has become acceptable in cases in which the indications have been correctly observed. We believe that salvage prostatectomy should be considered only for patients in good general health whose life expectancy is over 10 years and who have recurrent cancer confirmed by punch biopsy 1 year or longer after the completion of radiotherapy and whose cancer was initially in an early (T1-2) clinical stage before their radiotherapy. Ideally, serum PSA should be less than 10 ng/ml both initially (before radiotherapy) and before salvage surgery. In addition, patients should be highly motivated and able to accept the surgical morbidity (50% incontinence rate).