Elsevier

European Urology

Volume 61, Issue 5, May 2012, Pages 961-971
European Urology

Collaborative Review – Prostate Cancer
Cancer Control and Functional Outcomes of Salvage Radical Prostatectomy for Radiation-recurrent Prostate Cancer: A Systematic Review of the Literature

https://doi.org/10.1016/j.eururo.2012.01.022Get rights and content

Abstract

Context

Prostate cancer (PCa) recurrence following definitive radiation therapy (RT) remains a vexing challenge for the practicing physician. Salvage radical prostatectomy (SRP) has not been recognized yet as a valuable therapeutic option.

Objective

We critically analyzed the currently available evidence on SRP as to patient selection, predictive oncologic factors, surgical technique, cancer control, surgical complications, functional outcomes, and comparison to other salvage therapies.

Evidence acquisition

A systematic review of the literature was performed in June 2011 using the Medline, Embase, and Web of Science databases, limiting the review to English-language articles published between January 1980 and June 2011. All authors reviewed the list of references and added papers relevant to the topic of the review prior to the analysis. The panel selected 40 articles according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria.

Evidence synthesis

Positive surgical margins in SRP varied from 43% to 70% in earlier publications versus 0–36% in recent publications, and pathologic organ-confined disease (OCD) was found in 22–53% versus 44–73% in earlier versus recent publications. Biochemical recurrence–free probability after SRP ranged from 47% to 82% at 5 yr and from 28% to 53% at 10 yr. Cancer-specific survival (CSS) and overall survival varied from 70% to 83% and 54% to 89% at 10 yr. Pre-SRP prostate-specific antigen value and prostate biopsy Gleason score were the strongest prognostic risk factors for progression-free survival, OCD, and CSS. Open, laparoscopic, and robotic techniques were shown to be feasible in the hands of experienced surgeons. The most frequent complications included anastomotic stricture (7–41%) followed by rectal injury (0–28%). Major complications (modified Clavien classification grade 3–5) varied from 0% to 25%. Most complications were less frequent in more recent series, except for anastomotic stricture. The majority of patients had erectile dysfunction prior to SRP (50–91%) and 80–100% after SRP. Urinary continence ranged from 21% to 90% after surgery. Limitations of this review include the absence of prospective studies and lack of comparative analyses between SRP and other therapies.

Conclusions

In selected patients with confirmed, localized, radiation-recurrent PCa, SRP may effectively promote durable cancer control with acceptable associated surgical morbidity and variable functional recovery.

Introduction

The role of salvage radical prostatectomy (SRP) has evolved, with recent series showing improved results for the treatment of radiation-recurrent prostate cancer (PCa). Despite these reports, the vast majority of patients with radiation-recurrent PCa have been considered only for palliative systemic therapy [1]. Prior to the serum prostate-specific antigen (PSA) era, the difficulty of differentiating between local and distant recurrence as well as frequent surgical complications led to the exclusion of SRP from the management of radiation-recurrent PCa, except for a few referral centers. With the advent of improved patient selection and surgical technique, a different and promising scenario has been reported [2], [3], [4].

Currently, the majority of patients failing definitive radiation therapy (RT) for PCa are treated with androgen-deprivation therapy (ADT). However, most guidelines recommend SRP at experienced centers for a subset of patients with biochemical recurrence (BCR) not indicative of systemic relapse and studies negative for metastases [5], [6].

Because several confounding studies have addressed these issues over a long period of time and a comprehensive, updated review is currently lacking, we analyzed the currently available evidence concerning the main aspects of SRP: diagnosis, patient selection, predictive oncologic factors, surgical technique (open, laparoscopic, and robotic SRP), cancer control, surgical complications, and functional outcomes.

Section snippets

Evidence acquisition

A systematic literature review was performed in June 2011 using Medline, Embase, and Thomson-Reuters’ Web of Science. In the free-text protocol, the following terms were applied: salvage, radical, prostatectomy, radiorecurrent prostate cancer, and salvage therapy. The temporal limit was January 1980. Only English-language articles were considered for review. In addition, cited references from the selected articles and from review articles retrieved in the search were assessed for significant

Radiation-recurrent prostate cancer: definition and diagnosis

PCa recurrence after RT can be diagnosed by BCR or clinical evidence of disease, which usually occurs several years after BCR. BCR is defined by the American Society for Therapeutic Radiation and Oncology (ASTRO) as a rise in serum PSA by ≥2 ng/ml from a nadir PSA after RT and may represent either local or systemic disease recurrence [10]. Therefore, because this definition actually does not predict for local recurrence alone and instead predicts progression to metastatic disease and death from

Conclusions

Recurrent PCa represents a challenge for physicians, because currently available clinical and imaging tools poorly distinguish between local and distant failure. Managing patients with BCR after RT starts with an important treatment decision as to whether the patient is a candidate for further local therapy. Evidence supports that cancer control in a subset of patients with low-risk disease is more effective. Clinical predictors, such as PSA level and biopsy Gleason score, can be used to more

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