EAU PCa 2018: Salvage Radical Prostatectomy

Milan, Italy (UroToday.com) This was a session on local surgical salvage treatment for post-radiotherapy biochemical recurrence, and on surgical salvage lymphadenectomy. The purpose of radical salvage prostatectomy includes secondary local surgery with curative intent. We aim to improve the long-term cancer-specific survival, to maintain continence and potency, and to have a low percentage of surgery associated complications. Additionally, we want to prevent and treat local complications.

Dr. Heidenreich provided his personal experience (>350 cases of radical salvage prostatectomies) in how to choose the appropriate patients for salvage radical prostatectomy. Most importantly, biochemical recurrence the following radiotherapy should be established, local recurrence must be diagnosed through perineal or MRI fusion biopsy, absence of systemic/locoregional metastases must be confirmed (using the PSMA PET/CT scan), extraprostatic disease needs to be excluded (using mpMRI), bladder capacity and sphincter control need to be validated using urethrocystoscopy and urodynamics. Urethrocystoscopy should also be used to rule out urethral strictures, or bladder neck sclerosis. The patient should have a life expectancy of at least ten years, and he must be willing to accept increased local morbidity.

An important phenomenon that we need to be aware of is the PSA bounce phenomenon. A PSA bounce is defined as a temporary increase in PSA levels following radiotherapy, coupled with the following decrease in PSA, not resulting from kind of intervention. This may occur in 30% of the patients, and it lacks any prognostic effect on tumor control.

When assessing the functional and oncological outcomes of salvage radical prostatectomy, it appears that the continence rates are lower after three months when compared to primary radical prostatectomy. However, within nine months, the difference between primary and salvage radical prostatectomy incontinence is considerably lower.

The next topic briefly discussed was pelvic lymph node metastases following primary radical prostatectomy. Data has shown that post-radical prostatectomy patients with rising PSA and with positive PSMA PET/CT scans demonstrate relapse in the seminal vesicles in 8% of cases, a relapse in the pelvic lymph nodes in 36% of cases, and 10% of cases demonstrating relapse in the presacral/pararectal lymph nodes. Furthermore, 6.7% have a retroperitoneal recurrence, 8.6% have bony metastases, 3.3% have mediastinal metastases, and 2.8% have visceral metastases.  Salvage surgery can be attempted in these cases, although to date, there is no prospective level evidence on the effectiveness of this approach. It is reported that this management strategy brings down the PSA in approximately 30% of cases, but in the rest of the cases, PSA stays high, and patients continue to relapse. Prospective randomized studies are needed to figure out the best management strategy in these cases. We will undoubtedly hear and read more about these cases soon.

Presented by: Axel Heidenreich, Cologne, Germany

Written by: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre, Twitter:@GoldbergHanan at the 2nd EAU Update on Prostate Cancer  (PCa18)– September 14-15, 2018 – Milan, Italy