Recovery of erectile function after salvage radical prostatectomy for locally recurrent prostate cancer after radiotherapy

Salvage Radical Prostatectomy after Primary Focal Ablative Therapy: A Systematic Review and Meta-Analysis

CONTEXT

Focal therapy (FT) has been gaining popularity as a treatment option for localized intermediate-risk prostate cancer (PCa) due to the associated lower morbidity compared to whole-gland treatment. However, there is an increased risk of local cancer recurrence requiring subsequent treatment in a small proportion of patients.

OBJECTIVE

To conduct a systematic review and meta-analysis to better describe and analyze patient postoperative, oncologic, and functional outcomes for those who underwent salvage radical prostatectomy (sRP) to manage their primary FT failure.

EVIDENCE ACQUISITION

A systematic review was completed using three databases (PubMed, Embase, and CINAHL) from October to December 2021 to identify data on outcomes in patients who received sRP for cancer recurrence after prior focal treatment.

EVIDENCE SYNTHESIS

12 articles (482 patients) were included. Median time to sRP was 24 months. Median follow-up time was 27 months. A meta-analysis revealed a postoperative complication rate of 15% (95% CI: 0.09, 0.24), with 4.6% meeting criteria for a major complication Clavien (CG) grade ≥3. Severe GU toxicity was seen in 3.6% of the patients, and no patients had severe GI toxicity. Positive surgical margins (PSM) were found in 27% (95% CI: 0.19, 0.37). Biochemical recurrence (BCR) after sRP occurred in 23% (95% CI: 0.17, 0.30), indicating a BCR-free probability of 77% at 2 years. Continence (pad-free) and potency (ability to have penetrative sex) were maintained in 67% (95% CI: 0.53, 0.78) and 37% (95% CI: 0.18, 0.62) at 12 months, respectively.

CONCLUSION

Our evidence shows acceptable complication rates and oncologic outcomes; however, with suboptimal functional outcomes for patients undergoing sRP for recurrent PCa after prior FT. Inferior outcomes were observed for salvage treatment compared to primary radical prostatectomy (pRP). More high-quality studies are needed to better characterize outcomes after this sequence of PCa treatments.

PATIENT SUMMARY

We looked at treatment outcomes and toxicity for men treated with sRP for prior FT failure. We conclude that these patients will have significant detriment to genitourinary function, with outcomes being worse than those for pRP patients.

Hyaluronic acid spacer in focal prostate reirradiation: A single centre experience

PURPOSE

The optimal management of locally recurrent prostate cancer after curative radiotherapy is still unknown. In this study, we evaluated the preliminary results of reirradiation using stereotactic body radiotherapy for locally recurrent prostate cancer after initial definitive local radiotherapy.

MATERIALS AND METHODS

Between April 2016 and February 2019, 11 patients with recurrent disease at the previously irradiated prostate were treated. Local recurrence was detected by radiological with or without functional imaging modalities including prostate multiparametric/pelvic MRI or positron-emission tomography-computerised tomography with (⁶⁸Ga)-labelled prostate-specific membrane antigen performed after rising prostate specific antigen serum level during follow-up. All patients received stereotactic body radiotherapy to the recurrent nodule to a total dose of 30Gy in five fractions. Hyaluronic acid spacer was injected between prostate and rectum in seven patients to decrease the rectal dose. Acute toxicity was evaluated by using Common Terminology Criteria for Adverse Events version 4.0, and late toxicity was evaluated by using Radiation Therapy Oncology Group/European Organisation for Research and Treatment of Cancer late radiation morbidity scoring schema.

RESULTS

At the diagnosis, the median age was 64 years, and the mean prostate specific antigen serum concentration was 17.7ng/mL. The median interval time between local recurrence and initial definitive radiotherapy was 63 months. Mean prostate specific antigen concentration nadir value during follow-up was 0.43ng/mL. With a median follow up of 19 months, three patients developed either local or distant relapse. One patient had grade 3 acute rectal toxicity, and one patient had grade 2 late urinary toxicity. We did not observe any acute or late toxicity due to hyaluronic acid spacer injection.

CONCLUSION

Reirradiation after local recurrence following initial definitive radiotherapy together with hyaluronic acid spacer use seems to be effective and safe.

Nerve-sparing in salvage robot-assisted prostatectomy: surgical technique, oncological and functional outcomes at a single high-volume institution

OBJECTIVE

To show the feasibility, oncological and functional outcomes of neurovascular bundle (NVB) preservation during salvage robot-assisted radical prostatectomy (RARP).

PATIENTS AND METHODS

In the present institutional review board-approved retrospective analysis, between January 2008 and March 2016, 80 patients underwent salvage RARP, performed by a single surgeon (V.P), because of local recurrence after primary treatment. These patients were categorized into two groups depending on the degree of nerve-sparing (NS) performed: a good-NS group (≥50% of NVB preservation) and a poor-NS group (<50% of NVB preservation). A standard transperitoneal six-port technique, using the DaVinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA), was performed, and either an anterograde or a retrograde approach was used for NVB preservation. Validated questionnaires were used preoperatively (Sexual Health Inventory for Men [SHIM] and American Urological Association scores). Potency after salvage RARP was defined as the ability to achieve a successful erection with penetration >50% of the time, while full continence after salvage RARPwas defined as 0 pads used. The Kaplan-Meier method was used for survival and predictive estimations, and regression models were used to identify the predictors of potency, continence and biochemical failure (BCF).

RESULTS

The potency rate at 12 months was higher in the good-NS group (25.6% vs 4.3%; P = 0.036) regardless of previous SHIM score, and good NS tended to be predictive of potency after salvage RARP (P = 0.065). The full continence rate at 12 months and BCF rate were similar in the two groups, and non-radiation primary treatment was the only predictor of continence at 12 months after salvage RARP (P = 0.033).

CONCLUSIONS

Our data support the feasibility and safety of NVB preservation for salvage RARP conducted in select patients in a high-volume institution and the subsequent better recovery of adequate erections for intercourse.

[Salvage radical prostatectomy for recurrent prostate cancer. Morbidity, oncological and functional results]

INTRODUCTION

Salvage radical prostatectomy (sRP) for radiorecurrent prostate cancer (PCa) is a challenging procedure. To report our experience with sRP for selected patients with local recurrence after primary treatment for localised PCa.

METHODS

From 2005 to 2015, 24 patients underwent sRP for recurrent PCa in our center and were included in this retrospective study. Local recurrence was suspected by PSA increase>nadir+2ng/mL and was confirmed by biopsy. Perioperative complications according to Clavien-Dindo classification, oncological and functional results were analysed.

RESULTS

Overall, 24 patients with a median age of 59 years (IQR: 55-60) were included. Median follow-up was 25 months (IQR: 9-26). Procedures were performed with open-retropubic approach in 50 % and robot-assisted laparoscopic approach in 50 %. Overall, 5 (21 %) and 2 (8 %) patients experienced grade≤IIIa and grade≥IIIb postoperative complication, respectively. Surgical margins were positive in 46 % of cases. Three out of 4 patients with postoperatively detectable PSA (>0.2ng/mL) had positive surgical margins. Seven patients experienced biochemical recurrence in a median delay of 19 months (9-62). Seventy-one percent (5) of these patients experienced clinical recurrence in a median delay of 24 months (10-113). Severe urinary incontinence (≥3 pads/day) and erectile dysfunction were reported in 25 % and 63 %, respectively.

CONCLUSION

sRP for patients is a feasible procedure with encouraging local control rate and acceptable morbidity. This technique should be discussed as a treatment option for locally recurrent PCa in well-selected patients.

LEVEL OF EVIDENCE

4.

Focal salvage therapy for local prostate cancer recurrences after primary radiotherapy: a comprehensive review

Background/Aim

Patients with locally recurrent prostate cancer after primary radiotherapy can be eligible for salvage treatment. Whole-gland salvage techniques carry a high risk of toxicity. A focal salvage approach might reduce the risk of adverse events while maintaining cancer control in carefully selected patients. The aim of this review was to evaluate current literature to assess whether focal salvage leads to a comparable or favourable recurrence rate and less toxicity compared to whole-gland salvage.

Methods

A literature search was performed using PubMed, Embase and the Cochrane Library. A total of 3015 articles were screened and assessed for quality. Eight papers [on focal cryoablation (n = 3), brachytherapy (n = 3) and high-intensity focused ultrasound (n = 2)] were used to report outcomes.

Results

One-, 2-, 3- and 5-year biochemical disease-free survival (BDFS) ranges for focal salvage are, respectively, 69–100, 49–100, 50–91 and 46.5–54.5 %. Severe genitourinary, gastrointestinal and sexual function toxicity rates are 0–33.3 %. One study directly compares focal to whole-gland salvage cryotherapy, showing 5-year BDFS of, respectively, 54.4 and 86.5 % with lower toxicity rates for focal salvage patients.

Conclusion

Provisional data suggest that BDFS rates of focal salvage are in line with those of whole-gland approaches. There is evidence that focal salvage could decrease severe toxicity and preserve erectile function.

Electronic supplementary material

The online version of this article (doi:10.1007/s00345-016-1811-9) contains supplementary material, which is available to authorized users.

Salvage radical prostatectomy after external beam radiation therapy: a systematic review of current approaches

BACKGROUND

Radical external beam radiotherapy (EBRT) is a standard treatment for prostate cancer patients. Despite this, the rate of intraprostatic relapses after primary EBRT is still not negligible. There is no consensus on the most appropriate management of these patients after EBRT failure. For these patients, local salvage therapy such as radical prostatectomy, cryotherapy, and brachytherapy may be indicated.

OBJECTIVE

The objectives of this review were to analyze the eligibility criteria for careful selection of appropriate patients and to evaluate the oncological results and complications for each method.

METHODS

A review of the literature was performed to identify studies of local salvage therapy for patients who had failed primary EBRT for localized prostate cancer.

RESULTS

Most studies demonstrated that local salvage therapy after EBRT may provide long-term local control in appropriately selected patients, although toxicity is often significant.

CONCLUSIONS

Our results suggest that for localized prostate cancer recurrence after EBRT, the selection of a local treatment modality should be made on a patient-by-patient basis. An improvement in selection criteria and an integrated definition of biochemical failure for all salvage methods are required to determine which provides the best oncological outcome and least comorbidity.

Salvage focal prostate cryoablation for locally recurrent prostate cancer after radiotherapy: initial results from the cryo on-line data registry

BACKGROUND

Several investigators have tried to apply salvage focal prostate cryoablation to small numbers of patients with biopsy-proven unilateral recurrent prostate cancer (PCa) after radiotherapy with the aim of decreasing complications of salvage cryoablation. We report contemporary outcomes of salvage focal cryoablation for locally recurrent PCa after radiotherapy within the Cryo On-Line Data (COLD) Registry.

METHODS

We queried the COLD Registry to identify patients diagnosed as locally recurrent PCa after radiotherapy and treated with salvage focal cryoablation. Patients with hormone ablation after cryotherapy were excluded. The biochemical disease-free survival and morbidities were analyzed. Biochemical failure was defined using the Phoenix definition.

RESULTS

From 2002 to 2012, 91 patients with biopsy-proven radio-recurrent PCa underwent salvage focal cryoablation with curative intent. The biochemical disease-free survival rates were 95.3%, 72.4%, and 46.5% at 1, 3, and 5 years, respectively. Positive biopsies after salvage focal cryoablation were observed in four of 14 patients who underwent biopsy (28.6%). Rectourethral fistula was observed in three cases (3.3%). Urinary retention was observed in six cases (6.6%). Incontinence (requiring pad use) was reported in five cases (5.5%). Intercourse was reported in 10 of 20 patients (50%) who reported potency before salvage focal cryoablation.

CONCLUSIONS

The outcomes from this observational study indicate that salvage focal cryoablation can be an effective treatment with encouraging potency preservation for patients with locally recurrent PCa after radiotherapy. However, other morbidity including rectourethral fistula and incontinence are not clearly lower than for patients treated with salvage whole gland cryoablation. Studies with longer follow-up, more patients, and direct comparison to salvage whole gland cryoablation are needed before recommending salvage focal cryoablation as a standard treatment option for these patients.

[Salvage prostatectomy. Principles of diagnostics and operative therapy]

Organ-confined prostate cancer can be treated with curative intent by different types of radiotherapy or by radical surgery. Regardless of improvements in radiotherapy about 60% of patients with prostate cancer develop biochemical recurrence (BCR) which is defined by the progressive increase in serum prostate-specific antigen (PSA) and necessitates further diagnostic procedures. If non-organ-confined cancer and metastasis are categorically excluded by cross-sectional imaging using computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography CT (PET-CT) and bone scintigraphy, a prostate biopsy should be performed. Biopsy proven detection of recurrent or persisting prostate cancer after irradiation is essential prior to a salvage prostatectomy. The function of the lower urinary tract should be evaluated prior to surgery. Preoperative PSA measurement is the best prognostic indicator prior to surgery. Salvage prostatectomy in irradiated patients is more challenging and requires extensive skill. The most common complications are incontinence, rectal injury and anastomotic strictures. Both functional and oncologic outcome have improved due to better irradiation techniques and surgical skills. Provided post-radiotherapy recurrence of prostate cancer is diagnosed early enough, curing is possible by salvage prostatectomy.

[HIFU for prostate cancer in patients with a history of severe colorectal disease]

OBJECTIVES

To report the functional and oncological outcomes of HIFU for prostate cancer in patients with a history of severe colorectal disease.

METHODS

Between 2002 and 2009, 14 patients with a history of severe colorectal disease (cancer, lymphoma, inflammatory bowel diseases [IBD]) were treated with HIFU as a primary care option for localized prostate cancer.

RESULTS

Mean age was 65.8 ± 6.1 years. Mean time between colorectal disease treatment and HIFU was 10.6 ± 6.8 years. The mean Prostate Specific Antigen (PSA) before HIFU was 12.1 ng/mL (4.5-55). Gleason score was inferior or equal to 6 in four patients (28.6%), equal to 7 in nine patients (64.3%) and superior or equal to 8 in one patient (7.1%). The mean prostate volume before HIFU was 22.1 ± 11.7 mL. The number of HIFU sessions per patient was 1.35. The mean nadir PSA was 0.61 ± 0.82 ng/mL. Systematic control biopsies were negative in seven patients (50%). Mean follow-up was 22 months with a 35.7% complication rate (three erectile dysfunctions, two urinary stress incontinences). No recto-urethral fistula occurred.

CONCLUSION

HIFU was an interesting therapy for patients with a history of colorectal disease for whom regular treatment was challenging or non feasible.

Predicting biochemical recurrence-free survival for patients with positive pelvic lymph nodes at radical prostatectomy

PURPOSE

We evaluated predictors of freedom from biochemical recurrence in patients with pelvic lymph node metastasis at radical prostatectomy.

MATERIALS AND METHODS

Of 207 patients with lymph node metastasis treated with radical prostatectomy and bilateral pelvic lymph node dissection 45 received adjuvant androgen deprivation therapy and 162 did not. Cox proportional hazards regression models were used to investigate predictors of biochemical recurrence after radical prostatectomy. Recurrence probability was estimated using the Kaplan-Meier method.

RESULTS

A median of 13 lymph nodes were removed. Of the patients 122 had 1, 44 had 2 and 41 had 3 or greater positive lymph nodes. Of patients without androgen deprivation therapy 103 had 1, 35 had 2 and 24 had 3 or greater positive lymph nodes while 69 experienced biochemical recurrence. Median time to recurrence in patients with 1, 2 and 3 or greater lymph nodes was 59, 13 and 3 months, respectively. Only specimen Gleason score and the number of positive lymph nodes were independent predictors of biochemical recurrence. Recurrence-free probability 2 years after prostatectomy in men without androgen deprivation with 1 positive lymph node and a prostatectomy Gleason score of 7 or less was 79% vs 29% in those with Gleason score 8 or greater and 2 or more positive lymph nodes.

CONCLUSIONS

Prognosis in patients with lymph node metastasis depends on the number of positive lymph nodes and primary tumor Gleason grade. Of all patients with lymph node metastasis 80% had 1 or 2 positive nodes. A large subset of those patients had a favorable prognosis. Full bilateral pelvic lymph node dissection should be done in patients with intermediate and high risk cancer to identify those likely to benefit from metastatic node removal.

Current salvage methods for recurrent prostate cancer after failure of primary radiotherapy

We reviewed the current salvage methods for patients with local recurrent prostate cancer after primary radiotherapy (RT), using a search of relevant Medline/PubMed articles published from 1982 to 2008, with the following search terms: 'radiorecurrent prostate cancer, local salvage treatment, salvage radical prostatectomy (RP), salvage cryoablation, salvage brachytherapy, salvage high-intensity focused ultrasound (HIFU)', and permutations of the above. Only articles written in English were included. The objectives of this review were to analyse the eligibility criteria for careful selection of appropriate patients and to evaluate the oncological results and complications for each method. There are four whole-gland re-treatment options (salvage RP, salvage cryoablation, salvage brachytherapy, salvage HIFU) for RT failure, although others might be in development or investigations. Salvage RP has the longest follow-up with acceptable oncological results, but it is a challenging technique with a high complication rate. Salvage cryoablation is a feasible option, especially using third-generation technology, whereby the average biochemical disease-free survival rate is 50-70% and there are fewer occurrences of severe complications such as recto-urethral fistula. Salvage brachytherapy, with short-term cancer control, is comparable to other salvage methods but depends on cumulative dosage limitation to target tissues. HIFU is a relatively recent option in the salvage setting. Both salvage brachytherapy and HIFU require more detailed studies with intermediate and long-term follow-up. As these are not prospective, randomized studies and the definitions of biochemical failure varied, there are limited comparisons among these different salvage methods, including efficacy. In the focal therapy salvage setting, the increased use of thermoablative methods for eligible patients might contribute to reducing complications and maintaining quality of life. The problem to effectively salvage patients with locally recurrent disease after RT is the lack of diagnostic examinations with sufficient sensitivity and specificity to detect local recurrence at an early curable stage. Therefore, a more strict definition of biochemical failure, improved imaging techniques, and accurate specimen mapping are needed as diagnostic tools. Furthermore, universal selection criteria and an integrated definition of biochemical failure for all salvage methods are required to determine which provides the best oncological efficacy and least comorbidity.

[The role of surgery in locally advanced prostate cancer]

Recent retrospective monocentric studies have demonstrated favorable 15-year cancer-specific survival (CSS) rates of up to 86% using radical prostatectomy as part of multimodal treatment in locally advanced prostate cancer (T3-4, N0, M0). Patients most likely to benefit from surgery include those with a biopsy Gleason score < or =8, a prostate-specific antigen level <20 ng/ml, and cT3a cancer. Patients must be informed that additional treatment after prostatectomy might be necessary (30-70%; radiotherapy, hormonal therapy). Urinary incontinence may occur in up to 20%, and severe incontinence (more than two pads per day) is observed in up to 6%.Adjuvant radiotherapy should be considered individually and is not routinely recommended. Extended pelvic lymphadenectomy should be performed, although it has only a minor impact on survival. However, even in patients with lymph node micrometastasis, 10-year CSS can be achieved in 85.6% with the use of additional hormonal therapy. Cancer progression can possibly be delayed by surgical excision of the primary tumor, even in patients with metastasis. The existing data must be checked in prospective randomized trials.

Outcomes after radical prostatectomy in men receiving previous pelvic radiation for non-prostate malignancies

OBJECTIVE

To report the perioperative and functional outcomes of nine patients treated at our institution who had radical prostatectomy (RP) after previous pelvic radiotherapy (RT) for non-prostate malignancies.

PATIENTS AND METHODS

From 1993 to 2007, nine patients had RP after external beam RT for testicular seminoma (six), anorectal cancer (two) and colon cancer (one). Clinical information was obtained from a prospective prostate cancer database.

RESULTS

RP was completed with no identifiable injury to adjacent structures in all nine patients. Four patients had significant pelvic fibrosis, and three required bilateral neurovascular bundle (NVB) resection. The NVB was preserved in the remaining six patients, four with good preoperative erectile function. However, no patient recovered erectile function after RP at a median (range) follow-up of 75 (12-172) months. Of seven men continent before RP, four required one or fewer pads daily and three were completely dry, achieving complete urinary control at a median (range) time of 7.5 (2-20) months. Two patients developed an anastomotic stricture, one being associated with concomitant ureteric stricture.

CONCLUSIONS

RP after pelvic RT for non-prostate malignancies was not associated with increased intraoperative morbidity. However, rates of anastomotic stricture, erectile dysfunction and urinary incontinence appeared to be higher than those reported after RP in men with no previous RT, and comparable with those seen in the salvage RP setting.

Salvage radical prostatectomy for radiorecurrent prostate cancer: Indications and results

AIMS

A rise in the incidence of radiorecurrent prostate cancer is to be expected, since approximately one third of early prostate cancer cases are nowadays treated with a radiotherapy modality. One possibility in treating radiorecurrent prostate cancer is salvage prostatectomy. Our objective was to look into our own experience with salvage radical prostatectomy and to analyse outcome and morbidity.

METHODS

A computer search through our hospital database identified 11 patients who underwent a salvage radical prostatectomy for radiorecurrent cancer over the last 15 years. All data were retrospectively analysed and confronted with the literature.

RESULTS

Although the surgery was mostly difficult, there were no intraoperative complications. Bladder neck stricture is the most common postoperative complication (18%). Continence rates are worse than in classical radical prostatectomy. All patients lost potency, since no attempt was made to spare the neurovascular bundles. With a mean follow-up of 6.9 years, biochemical disease-free survival rates was 55%, while overall and cancer-specific survival was 91%.

CONCLUSION

While most patients with radiorecurrent prostate cancer will be treated by many experts with hormonal therapy, a salvage radical prostatectomy can give a second chance for cure in carefully selected patients.

Salvage prostate cryoablation after primary interstitial brachytherapy failure: a feasible approach

Salvage treatment for recurrent prostate cancer remains a very difficult and challenging field in urologic oncology. The introduction of minimally invasive surgical procedures such a targeted cryoablation brings some hope with its feasibility and efficacy to become a potentially curable treatment. We present the case of a 75-year-old male with prostate cancer treated primarily by brachytherapy, who developed late locally recurrent disease that was successfully treated with targeted salvage cryoablation.