MAJOR SURGERY TO MANAGE DEFINITIVELY SEVERE COMPLICATIONS OF SALVAGE CRYOTHERAPY FOR PROSTATE CANCER

Results of the York Mason Procedure with and without Concomitant Graciloplasty to Treat Iatrogenic Rectourethral Fistulas

BACKGROUND

Rectourethral fistulas (RUFs) are rare but devastating complications after surgery or radiation therapy to the urethra, prostate, or rectum. RUF repair is challenging, especially in irradiated patients.

OBJECTIVE

To evaluate the efficacy of the York Mason (YM) procedure with or without concomitant gracilis muscle interposition (graciloplasty) for RUF repair.

DESIGN, SETTING, AND PARTICIPANTS

Records of patients with an iatrogenic RUF who underwent the YM procedure between 2008 and 2018 in two university hospitals were reviewed. Data on etiology, diagnostic and operative procedures, urinary and fecal diversion, and postoperative follow-up were collected.

INTERVENTION

Twenty-eight patients underwent 33 YM procedures. Concomitant graciloplasty was performed in four (14%) primary repairs and two (7%) repairs for recurrent RUFs.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was successful RUF repair, defined as absence of symptoms and no leakage on control urethrocystography. The secondary endpoint was colostomy reversal rate.

RESULTS AND LIMITATIONS

Median follow-up was 24 mo. Ten patients (36%) were irradiated previously. The ultimate success rate was 75% after a maximum of three YM procedures. Success rates were 89% and 50% in patients with nonirradiated and irradiated fistulas, respectively. In irradiated patients, the success rates of the first YM procedure with and without graciloplasty were 100% and 29%, respectively. In recurrent cases, concomitant graciloplasty did not result in better outcomes. Colostomy reversal was possible in 15 patients after successful repair. In all patients, fecal continence was intact and no anal stenosis was reported. Limitations of the study include small sample size and the retrospective design.

CONCLUSIONS

Combination of the YM procedure with graciloplasty resulted in higher success rates of RUF repair in patients with irradiated fistulas. Fecal continence was preserved, and colostomy reversal is feasible.

PATIENT SUMMARY

We analyzed the outcomes, complications, and colostomy reversal rate of the York Mason procedure for the repair of rectourethral fistulas (RUFs). We found that concomitant graciloplasty increases success rates in case of prior radiation therapy. Colostomy reversal is feasible after RUF repair.

Surgical management of complex rectourethral fistulas in irradiated and nonirradiated patients

BACKGROUND

Rectourethral fistulas are an uncommon, yet devastating occurrence after treatment for prostate cancer or trauma, and their surgical management has historically been nonstandardized. Anecdotally, irradiated rectourethral fistulas portend a worse prognosis.

OBJECTIVE

To review outcomes after surgical treatment of rectourethral fistulas in radiated and nonirradiated patients to construct a logical surgical algorithm.

DESIGN AND SETTING

A retrospective review was undertaken of all patients presenting to Duke University with the diagnosis of rectourethral fistula from 1996 to 2012.

PATIENTS

Thirty-seven patients presented with and were treated for rectourethral fistulas: 21 received radiation, and a rectourethral fistula from trauma or iatrogenic injury developed in 16.

MAIN OUTCOME MEASURES

The groups were compared regarding their functional outcomes, including healing, time to healing, continence, and recurrence.

RESULTS

There were no significant differences in patient characteristics between groups. Patients who had irradiated rectourethral fistulas had a significantly higher rate of passage of urine through the rectum and wound infections, a higher rate of crystalloid infusion and blood transfusion requirements, and a longer time to ostomy reversal than nonirradiated patients. Patients who had irradiated rectourethral fistulas underwent more complex operative repairs, including gracilis interposition flaps (38%) and pelvic exenterations (19%), whereas nonirradiated patients most commonly underwent a York-Mason repair (50%). There were no statistically significant differences in rectourethral fistula healing or in postoperative and functional outcomes. Only 55% of irradiated patients had their ostomy reversed versus 91% in the nonirradiated group.

LIMITATIONS

This study was limited by the small sample size and the retrospective nature of the review.

CONCLUSIONS

Repair of rectourethral fistulas caused by radiation has a significantly higher wound infection rate and median time to healing, and lower overall stomal reversal rate than nonradiation-induced rectourethral fistulas. Patients who had irradiated rectourethral fistulas required significantly more complex operations, likely contributing to the higher morbidity, mortality, and lower fistula closure rate. We propose an algorithm for approaching rectourethral fistulas based on etiology.

Low temperature plasma: a novel focal therapy for localized prostate cancer?

Despite considerable advances in recent years for the focal treatment of localized prostate cancer, high recurrence rates and detrimental side effects are still a cause for concern. In this review, we compare current focal therapies to a potentially novel approach for the treatment of early onset prostate cancer: low temperature plasma. The rapidly evolving plasma technology has the potential to deliver a wide range of promising medical applications via the delivery of plasma-induced reactive oxygen and nitrogen species. Studies assessing the effect of low temperature plasma on cell lines and xenografts have demonstrated DNA damage leading to apoptosis and reduction in cell viability. However, there have been no studies on prostate cancer, which is an obvious candidate for this novel therapy. We present here the potential of low temperature plasma as a focal therapy for prostate cancer.

Focal salvage therapy for locally recurrent prostate cancer: a review

Objectives: To evaluate the current status of focal therapy as the salvage treatment option for patients with recurrent prostate cancer after established therapy (radiation, surgery) failure for localized tumor.
Methods: A MedLine search using specified search terms was done on December 23, 2011. This research rendered 346 papers related to High-Intensity Focused Ultrasound (HIFU), 644 papers related to cryosurgery, 180 related to photodynamic therapy and 3 articles related to radio frequency ablation. Very few of these papers presented original outcome data and are included in the present review.
Results: No controlled trial was available for analysis. 
Conclusions: Salvage HIFU in patients with local recurrence of prostate cancer after radical EBRT indicate is a reasonable treatment option, but better patient selection criteria are needed. It is a promising treatment option for local recurrence after radiation therapy, with morbidity comparable with other forms of salvage treatment. The side effects are not negligible but comparable with other forms of salvage treatment. Photodynamic therapy is a new option that could be suitable for organ-confined PC recurrence after radiotherapy, but the data are very few.

Surgical management of rectourethral fistula

OBJECTIVES

To present our experience and outcomes with the challenging problem of rectourethral fistula (RUF) using the perineal approach. RUF is a rare occurrence.

METHODS

This was a retrospective study of patients treated from January 1999 to December 2006. Fifteen patients (aged 16 to 64 years, mean 38) were studied, and their outcomes were assessed after surgical repair. The etiology was iatrogenic in 7, congenital in 5, and traumatic in 3. All patients presented with the passage of urine through the rectum and underwent micturating cystourethrography with retrograde urethrography, followed by preliminary cystoscopy and examination under anesthesia. All patients were treated using the perineal approach and gracilis muscle flap interposition. Six patients had associated urethral pathologic features that were managed simultaneously with RUF repair. Preoperatively, bowel diversion was done at the time of the cystourethroscopy and examination under anesthesia, if not done earlier, and the definitive repair was deferred for at least 12 weeks after bowel diversion.

RESULTS

RUF closure was successful in all the patients. Postoperatively, 2 patients had minimal urinary leakage through the perineum that resolved after repeat catheterization for 8 weeks. One stricture at the anastomotic site was managed with optical internal urethrotomy. One patient had extrusion of the gracilis flap, for which the muscle was repositioned.

CONCLUSIONS

The results of our study have shown that RUF closure using the perineal approach with pedicled gracilis muscle interposition is associated with low morbidity and a high success rate (100%). It is the method of choice for urologists because of their familiarity with the approach and because urethral pathologic features can be corrected simultaneously. We emphasize the need for bowel diversion before attempting reconstruction.

Transperineal repair of complex rectourethral fistula using gracilis muscle flap interposition--can urinary and bowel functions be preserved?

PURPOSE

Rectourethral fistula developing after prostate cancer treatment is usually complex and difficult to repair. We present our experience with 25 cases of complex rectourethral fistula using gracilis muscle interposition, addressing the efficacy of this technique as well as the postoperative urinary and fecal outcome.

MATERIALS AND METHODS

After receiving institutional review board approval we performed a retrospective chart review of patients with prostate cancer who had undergone gracilis muscle interposition for complex rectourethral fistula. A 1-page questionnaire was then mailed to all patients to assess urinary and bowel function.

RESULTS

At mean followup of 28 months all patients had successful fistula closure with no recurrence. Of the 18 patients (72%) with urinary continence 5 were continent after artificial urinary sphincter implantation. Three patients (12%) were totally incontinent and lost to followup. Four patients (16%) had permanent urinary diversion due to a devastated urinary outlet, while a urethral stricture was found in 5 and bladder neck contracture was noted in 3. Regarding bowel control, 19 patients (76%) were continent, 2 (8%) had fecal incontinence and 4 (16%) required permanent colostomy due to a devastated fecal outlet. A total of 17 patients replied to the mailed questionnaire for a 68% response rate and all had significant improvement in all parameters. Factors predisposing to a suboptimal outcome were large fistula size, surgery followed by radiation and cryotherapy.

CONCLUSIONS

Gracilis muscle transposition is an excellent procedure for treating complex rectourethral fistula. Several other local factors may affect the postoperative urinary and fecal outcome. The collaboration of colorectal and urological surgeons is necessary to achieve optimal results.

An algorithm for managing the failure of external beam radiotherapy in prostate cancer

OBJECTIVE

To present a management algorithm for men with prostate cancer recurring after external beam radiotherapy (EBRT), based on a review of published reports, to assist clinicians in identifying men who are suitable for salvage therapy and to help them to decide which type of salvage treatment is most likely to confer the desired outcome with the minimum of harm.

METHODS

Men with radiorecurrent prostate cancer require special consideration; they tend to be older, have more comorbidity and have worse disease than their contemporaries having primary treatment. Salvage treatment is compromised by the irradiated pelvis, resulting in increased treatment toxicity. Using the Pubmed database and reference lists of key articles, we identified studies relating to the management of radiorecurrent prostate cancer; the findings were incorporated into a management algorithm and summary table of treatments.

RESULTS

The American Society for Therapeutic Radiology and Oncology criteria, which define biochemical failure has now been superseded by the Phoenix definition (nadir prostate-specific antigen [PSA] plus 2 ng/mL). Biochemical follow-up after EBRT should be 3-monthly until the PSA level has reached a stable nadir after withdrawing androgen suppression. Contrast-enhanced dynamic magnetic resonance imaging (MRI) is an accurate tool and can be used for both the diagnosis and staging of patients with prostate cancer, in conjunction with prostate biopsies. Prostate biopsies should only be considered >2 years after EBRT to avoid false-positive results. In addition to MRI, high-risk cases being considered for salvage therapy should be considered for laparoscopic lymph-node dissection to exclude micrometastases. Deferred androgen suppression, laparoscopic or open radical prostatectomy, cryotherapy and high-intensity focused ultrasound all seem reasonable salvage treatment approaches.

CONCLUSION

Through improved methods of detection, including frequent PSA measurements, modern imaging and carefully obtained biopsies, those with radiorecurrent disease can be identified before their disease has spread. Rigorous staging will exclude those with micrometastases. The minimally invasive salvage therapies seem to offer an advantage over salvage surgery to patients in whom the benefits and harms are so finely balanced.

Management of asymptomatic rise in prostatic-specific antigen in patients with prostate cancer

Biochemical failure after curative-intent therapies is an increasingly common dilemma confronting patients and physicians. No definition of biochemical failure exists that can be applied to all forms of treatment and that is not to some degree affected by the follow-up interval, pretreatment prognostic factors, or the frequency of prostatic-specific antigen (PSA) testing. Available imaging techniques lack sensitivity in detection of occult micrometastases. Prognostic factors such as tumor characteristics and PSA kinetics should be considered when recommending second-line therapies. For those patients with suspected localized recurrence, second-line treatment with salvage therapies may provide long-term disease control. Hormonal therapy, although most commonly employed for PSA recurrence, is of palliative benefit only. Currently, the most appropriate therapeutic intervention for asymptomatic patients with evidence of biochemical failure remains undefined.

Patient selection, cancer control, and complications after salvage local therapy for postradiation prostate-specific antigen failure

Among men who experience prostate-specific antigen (PSA) failure after external beam radiation or brachytherapy (RT), many will harbor occult micrometastases; however, a significant minority will have a true local-only failure and, thus, potentially may benefit from a salvage local therapy. Those most likely to have a local-only failure initially have low-risk disease (PSA < 10 ng/mL, Gleason score < or =6, clinical T1c or T2a tumor status), pretreatment PSA velocity < 2.0 ng/mL per year at the time of initial presentation, interval to PSA failure > 3 years, PSA doubling time > 12 months, negative bone scan and pelvic imaging, and positive rebiopsy. In addition, men with presalvage PSA levels > 10 ng/mL, presalvage T3/T4 disease, or presalvage Gleason scores > or =7 on a rebiopsy sample without significant RT effects are unlikely to be cured by salvage local therapy. Based on a review of all series of post-RT salvage prostatectomy, cryosurgery, and brachytherapy published in English since 1990, morbidity can be substantial. Although urinary incontinence appeared to be greater after salvage prostatectomy (41%) or cryosurgery (36%) than after brachytherapy (6%), patients who received salvage brachytherapy faced a 17% risk of grade 3 or 4 genitourinary complications and a fistula risk that averaged 3.4% across all series. From this review, the authors concluded that prospective randomized studies are needed to determine the relative efficacy of the 3 major local salvage modalities and that additional research is needed to identify factors associated with an increased risk of significant complications to improve patient selection and to augment the benefit/risk ratio associated with attempts to cure local-only recurrences after radiation therapy.

Gracilis muscle transposition for fistulas between the rectum and urethra or vagina

PURPOSE

This study was designed to assess the efficacy of gracilis muscle transposition in repairing rectovaginal and rectourethral fistulas.

METHODS

Data were retrieved from a retrospective chart review of patients who underwent gracilis muscle transposition for fistulas between the rectum and urethra/vagina. All patients had fecal diversion as a preliminary or concurrent step to fistula repair. Follow-up data were gathered from outpatient clinic visits. Success was defined as a healed fistula after stoma closure.

RESULTS

Six females and three males, aged 30 to 64 years, underwent gracilis muscle transpositions from 1999 to 2005. One pouch-vaginal, three rectourethral, and five rectovaginal fistulas were repaired. The etiologies were Crohn's disease (n = 2), iatrogenic injury to the rectum during radical prostatectomy (n = 2), previous pelvic irradiation for rectal cancer (n = 2) or for cervical cancer (n = 1), recurrent perianal abscesses with fistulas (n = 1), and obstetric tear (n = 1). Seven patients underwent previous medical and surgical repair attempts. There were no intraoperative complications. Postoperative complications included perineal wound infection (n = 1) and at the colostomy closure (n = 2). There were no long-term sequelae. At a median follow-up period of 14 (range, 1-66) months since stoma closure, the fistula healed in seven patients. One patient refused ileostomy closure. One patient with severe Crohn's proctitis has a persistent rectovaginal fistula.

CONCLUSIONS

Gracilis muscle transposition is a viable option for repairing fistulas between the urethra, vagina, and the rectum, especially after failed perineal or transanal repairs. It is associated with low morbidity and a good success rate. Underlying Crohn's disease and previous radiation are associated with poor prognosis.

Management of radiotherapy induced rectourethral fistula

PURPOSE

An increasing number of men are being treated with BT or a combination of external beam radiation therapy and BT for localized prostate cancer. Although uncommon, the most severe complication following these procedures is RUF. We reviewed our recent experience with RUF following radiotherapy for prostate cancer to clarify treatment in these patients.

MATERIALS AND METHODS

We recently treated 22 men with RUF following primary radiotherapy for adenocarcinoma of the prostate in 21 and adjuvant external beam radiation therapy following radical prostatectomy in 1. Time from the last radiation treatment to fistula presentation was 6 months to 20 years.

RESULTS

Four patients underwent proctectomy with permanent fecal and urinary diversion. RUF repair in 5 patients was performed with preservation of fecal or urinary function. Six patients were candidates for reconstruction with preservation of urinary and rectal function, including 5 who underwent proctectomy, staged colo-anal pull-through and BMG repair of the urethral defect. The additional patient underwent primary closure of the rectum, BMG repair of the urethra and gracilis muscle interposition. Successful fistula closure was achieved in the 9 patients who underwent urethral reconstruction. All 8 candidates for rectal reconstruction showed radiological and clinical bowel integrity postoperatively with 2 awaiting final diverting stoma closure.

CONCLUSIONS

With the increasing use of prostate BT the number of patients with severe rectal injury will likely continue to increase. Radiotherapy induced RUF carries significant morbidity and most patients are treated initially with fecal and urinary diversion. In properly selected patients good outcomes can be expected following repair using BMG for the urethral defect along with colo-anal pull-through or primary rectal repair and gracilis muscle interposition.

Long-term results of suprapubic bladder neck closure for treatment of the devastated outlet

OBJECTIVES

To assess the long-term success of suprapubic bladder neck closure in patients with irreparably damaged bladder outlets.

METHODS

A cohort of 35 patients with intractable urinary incontinence secondary to severe posterior urethral/bladder neck damage underwent suprapubic bladder neck closure. Patients were assessed with regard to the success of procedure, as well as early and late complications.

RESULTS

With a mean follow-up of 79 months (range 12 to 164), suprapubic bladder neck closure was successful in 29 (83%) of 35 patients. One revision of the bladder neck improved the success rate to 94% (33 of 35). Early and late complications, excluding bladder neck fistula, were reported in 3 (9%) and 5 (14%) of 35 patients, respectively.

CONCLUSIONS

High success and acceptable complication rates can be achieved with suprapubic bladder neck closure for the treatment of severe urinary incontinence secondary to a devastated bladder outlet.

Role of Salvage Radical Prostatectomy for Recurrent Prostate Cancer After Radiation Therapy

Patients with isolated local recurrence of prostate cancer after radiation therapy may potentially be cured of their disease by salvage radical prostatectomy (RP). The stage-specific 5-year cancer-control rates of salvage RP resemble those of standard RP. However, the ability to effectively administer salvage treatment to patients with radiorecurrent disease is compromised by the lack of diagnostic tests with sufficient sensitivity and specificity to detect local recurrence at an early stage while it is amenable to local salvage therapy. By the time biochemical recurrence is declared using the current American Society for Therapeutic Radiology and Oncology definition, the majority of patients have advanced local disease, precluding successful local salvage therapy. When salvage RP is performed at prostate-specific antigen levels of 10 ng/mL or less, an estimated 70% of patients are free of disease at 5 years. With better patient selection and technical modifications, the morbidity associated with salvage RP has improved substantially. Rates of urinary incontinence and anastomotic stricture are acceptable, although one third of patients will experience these complications. Salvage cryotherapy is a minimally invasive alternative to salvage RP, but cancer-control rates appear to be inferior and it does not provide a clear advantage over salvage RP in terms of reduced morbidity. Patients with local recurrence after radiation therapy are at increased risk of metastatic progression and cancer-specific mortality. Currently, salvage RP represents the only curative treatment option for these patients. Salvage RP may favorably alter the natural history of biochemical recurrence after radiation therapy, but it must be instituted early in the course of recurrent disease to be effective.

Interstitial microwave thermal therapy and its application to the treatment of recurrent prostate cancer

Interstitial microwave thermal therapy may be an effective alternative to surgery for the treatment of some solid tumours. Arrays of helical antennae can produce complex heating patterns which when combined with active cooling of normal tissue structures can provide conformal heating for thermal coagulation of tumours. The development of a clinical protocol involving phantom and animal model studies, treatment planning, tissue property measurement and methods for on-line treatment monitoring is reviewed. The technology developed has been applied to the problem of recurrent prostate cancer following failed radiation treatment where available curative options are associated with high normal tissue morbidity. The purpose was to develop a treatment option for this group of patients with a very low side-effect profile that would not preclude further treatment if the disease progressed. Results of a Phase I/II trial demonstrate safety, promising efficacy and a low complication rate. As the technology for delivering this treatment matures, larger multi-institutional trials should be considered.

Complications of Prostate Cancer Treatment: Spectrum of Imaging Findings

The imaging appearances of prostate cancer are well described in the radiology literature, but little has been written about the detection and appearance of the complications of therapy for this disease. The most frequently used treatments for prostate cancer are surgical therapy (eg, radical retropubic prostatectomy, radical perineal prostatectomy), radiation therapy (eg, brachytherapy, external-beam radiation therapy, three-dimensional conformal radiation therapy, intensity-modulated radiation therapy), and cryoablative therapy, each of which may lead to complications with characteristic imaging appearances. Possible complications include lymphocele formation; injuries to the ureter, rectum, and urethra; prostatic necrosis; vesicourethral anastomotic leak and stricture; urethral stricture, necrosis, and fistula; radiation proctitis; transient bladder outlet obstruction; radiation-induced urethritis; urinary incontinence; and erectile dysfunction. With improvements in surgical techniques and advances in technology, complications of therapy for prostate cancer are decreasing but still occur with sufficient frequency to warrant familiarity on the part of radiologists. Knowledge of the diverse spectrum of these complications and their characteristic radiologic features facilitates prompt diagnosis and treatment.

Salvage brachytherapy for local recurrence after radical prostatectomy and subsequent external beam radiotherapy

OBJECTIVES

To evaluate the technical feasibility, safety, and efficacy of seed implantation for local recurrence after radical prostatectomy and external beam radiotherapy.

METHODS

Between October 1999 and March 2002, 10 patients with targeted, histologically proven local relapse after surgery and subsequent external beam radiotherapy (only in 8 patients), underwent permanent brachytherapy with palladium-103 and iodine-125 after complete restaging. In all patients, an intraoperative morphovolumetric ultrasound study of the target was performed, with a planning target volume ranging from 5 to 26.7 cm(3). The preimplant prostate-specific antigen values ranged from 1.1 to 6.31 ng/mL.

RESULTS

Postplan dosimetry was performed to determine the percentage of the target volume that received a dose equal to, or greater than, the prescribed dose (range 84.5% to 95.9%) and the dose that was delivered to the 90% of the target volume (range 85.08% to 129.43%). The urinary scores, measured using the International Prostate Symptom Score, had normalized at 3 months. Only 1 patient had worsened incontinence during the first 2 months, with subsequent restoration of the previous situation. The other patients did not have any changes in their previous clinical condition. One patient experienced occasional gross hematuria that had been present after external beam radiotherapy. No rectal complications were reported. After a median follow-up of 20.6 months, 7 patients showed a decreasing or stable prostate-specific antigen level.

CONCLUSIONS

This preliminary experience has demonstrated that seed implantation of a neoplastic local recurrence is technically feasible and safe and allows for accurate dosimetry when the area to be treated can be defined by ultrasonography. Longer follow-up, accurate patient selection, and larger series of patients could help to better define the oncologic outcome.

Gracilis muscle transposition for iatrogenic rectourethral fistula

OBJECTIVE

To assess the utility of gracilis muscle transposition in the treatment of iatrogenic rectourethral fistula.

SUMMARY BACKGROUND DATA

Iatrogenic rectourethral fistula poses a rare but challenging complication of treatment for prostate cancer. A variety of procedures have been described to treat this condition, none of which has gained acceptance as the procedure of choice. The aim of this study was to review the authors' experience with gracilis muscle transposition in the treatment of iatrogenic rectourethral fistula.

METHODS

A retrospective chart review of all patients who underwent gracilis muscle transposition for iatrogenic rectourethral fistula was performed, and follow-up was established by telephone interview. Successful repair was defined as absence of a fistula after reversal of fecal and urinary diversions.

RESULTS

Eleven men, mean age of 62 years, underwent 12 gracilis muscle transpositions for rectourethral fistula between 1996 and 2001. Six patients had a history of pelvic radiotherapy, and five patients had previous failed attempts to repair the fistula. In nine patients, the fistula healed following gracilis muscle transposition. One patient developed a rectocutaneous fistula that healed with fibrin glue injection, and one developed perineal sepsis requiring debridement of the transposed gracilis. This patient underwent a second gracilis transposition, which uneventfully healed. Overall, all of the patients had closure of their diverting stomas and maintained healed rectourethral fistulas. There were no intraoperative complications, and the only long-term complication of this procedure was mild medial thigh numbness in two patients.

CONCLUSIONS

Gracilis muscle transposition is an effective surgical treatment for iatrogenic rectourethral fistula. It is associated with low morbidity and a high success rate.

Salvage cryotherapy for recurrent prostate cancer after radiotherapy: variables affecting patient outcome

PURPOSE

To determine the long-term disease-specific survival (DSS) and disease-free survival (DFS) rates after salvage cryotherapy for locally recurrent adenocarcinoma of the prostate and to identify pretreatment factors that have an impact on DSS and DFS.

PATIENTS AND METHODS

Between July 1992 and January 1995, 131 patients who had received definitive radiation therapy (XRT) underwent salvage cryotherapy for locally recurrent adenocarcinoma of the prostate. Cryotherapy failure was defined as an increasing postcryotherapy prostate-specific antigen (PSA) level of > or = 2 ng/mL above the postcryotherapy nadir, a positive prostate biopsy, or radiographic evidence of metastatic disease. Clinical variables were studied to determine whether there was an association with the DSS and DFS.

RESULTS

The median follow-up was 4.8 years. The 5-year DSS rates were 87% for patients with a precryotherapy Gleason score < or = 8 and 63% for those with Gleason scores of 9 and 10 (P =.012). The 5-year DFS rates were 57% for patients with a precryotherapy PSA level of < or = 10 ng/mL and 23% for those with a PSA level greater than 10 ng/mL (P =.0004). The 5-year DSS rates for patients with a pre-XRT clinical stage of T1 to T2 and those with a clinical stage of T3 to T4 were 94% and 72%, respectively (P =.0041). The 5-year DFS rates for these groups were 90% and 69%, respectively (P =.0057).

CONCLUSION

Androgen-independent local recurrences, Gleason score, and pre-XRT clinical stage were important factors that had an impact on DSS and DFS. The subset of patients cured by salvage cryotherapy seems to be small, and patient selection is important.