Salvage radical prostatectomy for radiorecurrent prostate cancer: the Chinese experience

For localized prostate cancer, radiation therapy (RT) is commonly used. However, in the first five years of RT, 10%-20% of localized prostate cancer patients, and 30%-50% of the locally advanced prostate cancer patients will progress to biochemical recurrence. In the past, only few these patients considered salvage radical prostatectomy (SRP) as their primary selection due to the significant morbidity. With the improvement of surgical techniques and radiation technology, morbidity of SRP had decreased significantly in recent studies. We reported our experience of SRP at Shanghai Changhai Hospital from April 2005 to July 2011. This retrospective study involved 4 patients (Group 1) who was performed salvage prostatectomy, and 199 patients (Group 2) who were performed original open retropubic radical prostatectomy. For Group 1, the mean age was 67 (range 64–71) years old. They were considered a candidate for SRP when they had biopsy proven recurrent prostste cancer associated with increasing prostate specific antigen (PSA) levels.1 One had diabetes and preoperative blood glucose level was controlled normally. One had stop aspirin for 2 weeks before surgery. Blood pressure is controlled to under 140/90 mmHg before surgery. Four patients were primarily treated with the three dimension conformal radiotherapy (3D-CRT) with a mean dose 71 Gy (range 66–76). Mean PSA nadir (PSA value after radiation therapy) was 2.6 ng/ml (range 1.2–4.7) ng/ml. One had bicalutamide for 1 month. Mean presalvage PSA level was 6.35 (4.18–8.30) ng/ml. All patients were excluded metastatic spread with a bone scan and contrast enhanced CT scan of the pelvis. Prostate cancer was confirmed by transrectal prostate biopsy before salvage radical prostatectomy. For Group 2, the mean age was 68 (range 51–81) years old, and preoperation PSA level was 20.6 (1.7–100.0) ng/ml. Radical retropubic prostatectomy was performed and we used some unique techniques which had been described in our two previous articles.2 One 64 years old patient in Group 1 and 20 patients in Group 2, who had normal sex activity before surgery, was performed nerve sparing surgery. All the cases were performed open retropubic radical prostatectomy successfully. In Group 1, postoperative pathology results were prostate cancer, with the Gleason scores of 3+3, 3+4, 3+4 and 4+3. Three tumors were detected negative in prostate capsule, seminal vesicles, lymph nodes and cutting margins. One tumor was found tumor cells in right seminal vesicle and outside prostate capsule. Blood loss was 332.5 (140–560) ml, and the operative time was 178 minutes (132–261). Nine and a half days after surgery, the drainage tubes were moved. Three cases had no urinary leakage, and all the 4 cases had no lymphatic leakage. Postoperative follow-up of 20 (12–32) months, and 1 patient was diagnosed biochemical recurrence 5 months after surgery. Sixteen months after surgery, the patient died of bone and distance metastasis. Data concerning urinary continence were available for patients after 3 months, with 3 (75%) being dry or requiring 1 or fewer pads per day. In the follow-up time, no evidence of metastasis is achieved by PSA and bone ECT in the other 3 cases. In Group 2, blood loss was 200.5 ml (100–460 ml), and the operative time was 185 minutes (116–342). The average follow-up was 56.5 months. The 5 year biochemical recurrence free survival rate was 91%. Though the Group 2 has the less blood loss, there was not difference in operative time between the two groups. Compared to the previous two methods, SRP could achieve better oncological outcome in western populations.3 However, the international statistic data indicated that the actual SRP cases were far less than the cases which were suitable for SRP. The reasons can be listed below: (1) The severity and high rate of complications. The statistics of nine reported in the literature published 1991–1997 had revealed the highest incidence of urinary incontinence was up to 65%, with an average of 50.2%.4 (2) The patients who underwent radical radiotherapy are mostly fear of complications. So the decision was difficult for them to make with the higher rate of surgery complications than previous surgery. (3) In China, prostate cancer patients were more like to go to urologists but not radiologists, and the population of receiving radiotherapy is relatively small. (4) Because the detection rate of early prostate cancer is low in china, so the number of radical prostatectomy was less than that of foreign medical centers, thus the surgical skills which are important in doing SRP, are far from enough for Chinese surgeons.Table 1: Clinical data of the SRP patientsPrior to undergoing SRP, selecting the appropriate patients comes importantly. To get a better morbidity which is associated with Gleason score, PSA, whether for localized prostate cancer and life expectancy, early identification of biochemical recurrence post radiation therapy has to be confirmed. Presently, judgment of biochemical recurrence relies on two criteria. Recurrence post radiation was defined according to the American Society for Therapeutic Radiology and Oncology (ASTRO) definition in 1997 (3 successive rises in serum prostate-specific antigen above nadir, with the date of recurrence backdated to the midpoint between the nadir and first measurements).1 The new Phoenix definition of biochemical recurrence in 2006 was defined as a postoperative PSA >0.2 ng/ml and rising.4 The older ASTRO definition has been abandoned due to its lack of sensitivity and specificity. But in the selection of patients, patients confirmed of biochemical recurrence mostly according to Phoenix definition had a poor prognosis by the Salvage radical prostatectomy. Therefore, on the aspect of patient selecting, the first definition has its advantage. In the present study, patient selecting we rely on the criteria of 1997, and 3 of the 4 also meet the criteria of 2006. And one of the three patients died because of local and distance metastasis. That is to say, Phoenix definition can choose patients who have later tumor stage, and less benefit can be achieved from SRP. In conclusion, SRP is feasible if the urologist has extensive experience and was familiar with the anatomy of radical prostatectomy. Although the study achieved better tumor control and urinary control effect, the results need to be further studied because of the small amount of cases.