AUA 2018: Oncological Outcomes of Salvage Radical Prostatectomy in a Contemporary, Multicentre Series of 395 Cases

San Francisco, CA (UroToday.com) While radical prostatectomy is the most commonly utilized treatment for clinically localized prostate cancer in the United States, many patients undergo other treatments including radiotherapy (whether external beam or brachytherapy), cryotherapy, high-intensity focused ultrasound (HIFU), and others. When patients who have undergone these treatments experience biochemical recurrence, management options are not well described. In a moderated poster presented at the American Urologic Association Annual Meeting, Dr. Gontero and colleagues report on a large, multi-institutional cohort from 18 tertiary care centers describing the outcomes of salvage radical prostatectomy in this setting. The authors present data relating to pre-operative, intra-operative, and post-operative factors including functional recovery following surgery. 



Among the 18 centers included in the study, the authors identified a total of 395 eligible patients who had undergone salvage radical prostatectomy following another prior local therapy. Of these men, 67% underwent prior external beam radiotherapy, 22% prior brachytherapy, 4% prior cryotherapy, 3% prior HIFU, and 3% other prior treatments. As may be expected given the large intervention being undertaken, these men were relatively young (mean age at the time of surgery 66 years, interquartile range 62-71 years) and had relatively low levels of comorbidity (mean American Society of Anesthesia Class 2.2, standard deviation 0.8).  

At the time of salvage radical prostatectomy, the mean PSA was 6.4 ng/mL (interquartile range 2.5-7.3 ng/mL). Radiographically, none of these patients had extra-nodal disease burden. 143 men, representing 37% of the cohort, had been initiated on and were currently receiving hormone therapy and 15 (4%) had already progressed to castration resistant disease. 

With respect to operative factors, a variety of approaches were undertaking accounting for differences in patient factors, surgeon and institutional preference. 6 patients (2% of the cohort) underwent a “super-extended” lymphadenectomy including the retroperitoneum while 44 (14%) underwent nerve sparing procedures. The mean operative time was 221 minutes (interquartile range 150-250 minutes) and mean estimated blood loss was 439 cc (interquartile range 150-500cc). 

Pathologically, high grade histology (Gleason Score >=8) was identified in 152 patients (43%), locally advanced disease (T stage >=3) was found in 215 (55%) and lymph node involvement was found in 62 (19%). Just over half of all patients (n=165, 51%) had positive surgical margins. 

With respect to operative outcomes, 40 patients (10%) experienced at least one major complication (Clavien class >=3). Assessment of functional outcomes demonstrated significant rates of impotence (only 8% of patients with erections either spontaneously or with the use of PDE5i) and severe incontinence (26% of patients requiring >= 3 pads per day). Oncologically, 150 patients (48%) experienced subsequent biochemical recurrence and 20% progressed to castrate resistant disease over a median follow up of 3 years. Never the less, overall and cancer specific survival rates were high at 5 years, 95% and 96% respectively. 

The authors conclude that salvage radical prostatectomy may offer promising short to medium term oncologic outcomes. However, these come at the cost of significant operative and functional complications. 

Presented By: Paolo Gontero 
Co-authors: Giancarlo Marra, Paolo Alessio, Marco Oderda, Anna Palazzetti, Francesca Pisano, Antonino Battaglia, Stefania Munegato, Giorgio Calleris, Bruno Frea, Fernando Munoz, Claudia Filippini, Estefania Linares, Rafael Sanchez-Salas, Sanchia Goonewardene, Prokar Dasgupta, Declan Cahill, Ben Challacombe, Rick Popert, David Gillatt, Raj Persad, Juan Palou, Steven Joniau, Salvatore Smelzo, Thierry Piechaud, Alexandre De La Taille, Morgan Roupret, Simone Albissini, Roland Van Velthoven, Alessandro Morlacco, Sharma Vidit, Giorgio Gandaglia, Alexander Mottrie, Joseph Smith, Shreyas Joshi, Gabriel Fiscus, Andre Berger, Monish Aron, Henk Van Der Poel, Derya Tilki , Declan Murphy, Nathan Lawrentschuk, John Davis, Gordon Leung, Robert Jeffrey Karnes 

Written by: Christopher J.D. Wallis, Urology Resident, University of Toronto, Twitter: @WallisCJDat the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA
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