AUA 2020: Salvage Radical Prostatectomy for Recurrent Prostate Cancer: Oncological Outcomes of a Contemporary Multicenter Study

( Prostate cancer after primary non-surgical treatment of prostate cancer is common. The vast majority of recurring patients (~90%) undergo androgen deprivation therapy, regardless of the recurrence site. However, certain men with biochemical recurrence after primary treatment can be managed with curative intent by salvage radical prostatectomy. Historical series show high complication rates and poor outcomes, while better results are reported in novel robotic salvage radical prostatectomy procedures. At the American Urological Association (AUA) 2020 virtual annual meeting, Dr. Giancarlo Marra and colleagues presented results of their study assessing the contemporary oncological outcomes of salvage radical prostatectomy in a large multicenter recent series. 

Between 2000 and 2016, 629 men with biochemical recurrence underwent salvage radical prostatectomy at 18 tertiary referral centres. The authors retrospectively collected pre-, intra and post-surgery clinical and histological data. A follow up <6 months, pre-salvage radical prostatectomy castration-resistant disease, laparoscopic approach, or unavailability of the data with no revision were adopted as exclusion criteria. A post-operative PSA >0.2 ng/ml was used to define biochemical recurrence. Outcomes included grading, local staging, surgical margins at final pathology report, prostate-specific antigen (PSA) persistence rate after salvage radical prostatectomy, biochemical recurrence rate at 5 years, cancer-specific survival at 5 years and overall survival. A multivariable logistic regression model was used to test the predictor of biochemical recurrence and positive surgical margins. 

There was a total of 414 cases included, with a median PSA of 4.2 ng/ml. Primary treatment was represented by radiotherapy (63.5%), brachytherapy (25.7%) or other treatment (13.6%). Before primary treatment, 10% had ≥ Gleason 7 disease, and 11.5% had ≥ had cT2c disease. The median age at salvage radical prostatectomy was 66 years of age (IQR 62-70) and the median PSA was 4.2 ng/mL (IQR 2.5-7.3). At confirmatory biopsy before salvage surgery, more than half of the patients had Gleason score ≥7 (45.5%) and organ-confined, node-negative disease at imaging (93.3%). Final pathology showed higher grading in 39.7% (Gleason ≥9 27.6%) of patients, with more than half having non-organ-confined disease (≥pT3, 52.9%); pN1 was present in 16% of patients. Nearly 1 out of 3 patients had positive surgical margins (29.7%), and 26.9% were severely incontinent at 6 months, with a major complication rate of 18%. The 5-year biochemical recurrence-free survival rate was 56.7%, cancer-specific survival rate was 97.7%, and overall survival (OS) rate was 92.1%:  


On multivariate analysis: positive surgical margins were predicted by pT staging (pT3a OR 2.9, 95% CI 1.5-5.9; ≥pT3b OR 2.4, 95% CI 1.3-4.4) and nodal disease (pN1 OR 2.9, 95% CI 1.5-5.9); biochemical recurrence was associated with pT staging ≥T3b (OR 2.3 95% CI 1.3-4.1) and tumor grading (Gleason score > 8 OR 7.3, 95% CI 1.9-27.1). 

Dr. Marra summarized his presentation with the following concluding statements:

  • In this multicenter series, salvage radical prostatectomy yielded acceptable oncological outcomes on the short-medium term, notwithstanding the advanced pathological characteristics encountered at final pathology
  • Extra-organ disease and higher Gleason score enhance biochemical recurrence risk
  • However, at 5-years, a good proportion of men are disease-free. As such, salvage radical prostatectomy can be curative and should not be a priori precluded in well selected patients

Presented by: Giancarlo Marra, MD, Urology Resident, University of Turin, Torino, Italy

Co-Authors: Paolo Gontero, Paolo Alessio, Giorgio Calleris, Marco Oderda, Fernando Munoz, Claudia Filippini, Estefania Linares, Rafael Sanchez-Salas, Sanchia Goonewardene, Prokar Dasgupta, Ben Challacombe, Rick Popert, Declan Cahill, David Gillatt, Raj Persad, Juan Palou, Steven Joniau, Thierry Piechaud, Alexandre De La Taille, Morgan Roupret, Simone Albisinni, Alessandro Morlacco, Giorgio Gandaglia, Alexander Mottrie, Joseph Smith, Andre Berger, Monish Aron, Andre Abreu, Inderbir S. Gill, Henk Van Dar Poel, Derya Tilki, Declan Murphy, Nathan Lawrentschuk, John Davis, Robert Jeffrey Karnes

Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, Twitter: @zklaassen_md at the 2020 American Urological Association (AUA) Annual Meeting, Virtual Experience #AUA20, June 27- 28, 2020