UROLOGICAL ONCOLOGY

Perineal salvage prostatectomy for radiation resistant prostate cancer
van der Poel HG, Beetsma DB, van Boven H, Horenblas S
Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
Eur Urol. 2007; 51: 1565-71; discussion 1572

• Objectives: No data are available on the use of perineal prostatectomy for salvage treatment of local recurrent prostate cancer after radiotherapy. Here we report on the clinical aspects and follow-up of salvage perineal prostatectomy.
• Materials and Methods: Twenty-seven patients underwent a perineal salvage prostatectomy from 1997-2005 for biopsy-proven local recurrent prostate cancer after external beam (n = 22) or brachyradiotherapy (n = 5). Staging included physical examination, prostate-specific antigen (PSA), transrectal ultrasound, computed tomography scan, and bone scan.
• Results: Mean PSA before surgery was 8.6 ng/mL (± 2.8 ng/mL). Comparing clinical staging with final pathologic staging after salvage perineal prostatectomy showed a 67% clinical understaging. Mean blood loss was 677 cc, and perioperative morbidity consisted of prolonged anastomotic leakage (n = 8), urosepsis (n = 3), prolonged hematuria (n = 3), urinary retention (n = 2), and rectal perforation (n = 1). One patient died during the postoperative course because of urosepsis and endocarditis. At an interval of at least 12 mo after surgery, 37% (10 of 27) and 7% (2 of 27) of patients reported normal continence and erectile function, respectively. Five patients died during a mean follow-up of 43 mo; two patients died of prostate cancer. Five-year biochemical recurrence-free survival was 31% (95% CI, 25-42%). In a multivariate Cox regression analysis the serum PSA and PSA doubling time (PSADT) at the time of surgery were the best predictors of biochemical recurrence-free survival. No patient with a PSA > 2 ng/mL and a PSADT < 12 mo was without biochemical recurrence 2 yr after surgery.
• Conclusions: Salvage perineal prostatectomy showed functional results that favorably compare with the retropubic approach, but considerable morbidity is still frequent. Proper patient selection therefore is mandatory. A serum PSA level of > 2 ng/mL and PSADT < 12 mo independently predict shorter biochemical recurrence-free survival.
  
  
• Editorial Comment
  Data on salvage prostatectomy after previous radiotherapy are sparse. This report focuses on perineal prostatectomy in this patient group. Several interesting features in this report are worthwhile reporting and considering in patients with a similar situation.
  First, understaging is a major event. Fifty-eight percent of patients had positive surgical margins. This translates into low long-term cure rates that are given in Figure-1 of the manuscript. After 5 years, only 20% of patients still were free of PSA recurrence. Of further importance is the fact that only patients with a preoperative PSA of < 2 ng/mL remained free of biochemical recurrence.
  In fact, radical salvage prostatectomy remains a procedure that should be elected in few highly elected patients.

Dr. Andreas Bohle
Professor of Urology
HELIOS Agnes Karll Hospital
Bad Schwartau, Germany
E-mail: boehle@urologie-bad-schwartau.de