Short Communication Salvage radical prostatectomy for recurrent prostate cancer after radiation therapy Costantino Leonardo, 1 Giuseppe Simone, 2 Rocco Papalia, 2 Giorgio Franco, 1 Salvatore Guaglianone 2 and Michele Gallucci 2 1 Department of Urology, University of Rome, Rome, Italy, and 2 Department of Urology, Regina Elena Cancer Institute, Roma, Italy Abstract: Salvage radical prostatectomy is considered for patients with locally recurrent prostate cancer after external beam radiotherapy. Between 2001 and 2004, 32 men treated with curative intent with radiotherapy for prostate cancer were subsequently treated with salvage surgery for clinically localized prostate cancer. We assessed the morbidity associated with this procedure and the outcome of the patients. Thirty-two patients underwent salvage radical prostatectomy. Initial pre-radiation median prostate-specific antigen was 13 ng/ml. Pre-radiation disease was clinical stage T1b in five cases, T2a in 10, T2b in 10 and T3a in seven. Mean operative time was 122 minutes, intraoperative blood loss was 550 ml and hospital stay and catheterization time were 5 and 12 days, respectively. There was biochemical failure in eight patients after salvage radical prostatectomy and 24 patients are biochemical non evidence of disease (bNED). In recurrent prostate local disease with prostate-specific antigen <10 ng/ml and life expectancy greater than 10 years, salvage radical prostatectomy is a reasonable treatment option. Key words: prostate cancer, radiation therapy, radical prostatectomy, salvage surgery. Introduction The increase in early diagnosis of prostate cancer has and will continue in the future to lead to treatments such as radical prostatectomy (RP) and conformational radiotherapy (RT) at the organ-confined stage. In recent years curative RT has been applied more widely in order to treat disease, avoiding the side-effects associated with surgery. However, 30 to 50% of localized prostate cancer treated with RT has a biochemical progression over time. 1,2 There is a three-year time relapse between prostate-specific antigen (PSA) recurrence and the clinical evidence, without salvage therapy. Disease recurrence after RT is shown by persistently high PSA, an increase of PSA nadir and/or the presence of a positive biopsy, 12–18 months after RT. Currently the majority of patients receiving further therapy after RT are treated with hormone therapy. 3 Up to 70% of patients with a rise in PSA after RT have local recurrent disease. 4 In such cases salvage RP may necessitate an oncological control after some time and have similar results as standard RP at the same pathological stage. 5 In the past the significant associated morbidity has limited the number of patients undergoing salvage RP. 6,7 Recently an improvement in techniques has put salvage and standard surgery on a par. 5 We report on our cohort of 32 cases, and the clinical characteristics and follow up are discussed. Methods Between June 2001 and October 2004, 32 patients with local recur- rence of radio-treated prostate cancer underwent curative salvage RP. Clinical information regarding pre-RT clinical features, RT regimen and disease course following RT were extracted from our database. The average age of patients was 63 years (between 56 and 72 years). The patients underwent initial RT between 1994 and 2000 with a median dose of 68 Gy (between 66 and 70 years), with conventional in 10 cases and conformational RT in 22. Before RT the median PSA was 13 ng/ml (2–70), Gleason score at biopsy was 6, 5–8 and the clinical stage was T1b in five cases, T2a in 10, T2b in 10 and T3a in seven according to the International Union Against Cancer (UICC) 2002 tumor–node–metastases (TNM) classifi- cation (Table 1). None of the patients underwent pelvic lymphadenec- tomy before RT. Recurrence occurred after an average of 25 months (9–57) after RT and surgery was performed 11 to 60 months (median 31) after radiation treatment. According to the European Urological Association Guide- lines, biochemical failure after RT is defined as a rising PSA level rather than a specific threshold value. The selection criteria for salvage RT included a life expectancy of more than 10 years, absence of systemic disease and persistent prostate cancer detected by biopsy. Five patients had hormonal therapy between diagnosis of recurrence and surgery. Before salvage RP the average PSA was 2.3 (2–10) and in all cases a prostatic biopsy was carried out. In all cases, carcinoma with an average Gleason score of 7 (range 6–8) was detected. Neoadjuvant hormonal therapy did not exclude or hinder the performance of Gleason grading. The pre-surgery clinical stage was T2 in 28 cases and in four other cases it was T3. As regards preoperative continence, only 2 of 32 patients used >1 pad/day. Only 3 of 32 were preoperative-potent. The salvage RP technique was a standard open retropubic approach with an extended lymph node dissection. Because of the extensive periprostatic fibrosis induced by the radia- tion therapy, difficulty is typically encountered in the dissection of three main areas: prostatic apex, dorsal vein complex, and urethra. In general we performed a combined retrograde and antegrade dissection in order to reduce the rectal injury. As concerns urinary continence, the patients were evaluated as con- tinent, if one pad or less a day was needed without treatment for incontinence. Potency was defined as normal erections during inter- course, with or without sildenafil. Disease progression after salvage RP Correspondence: Constantino Leonardo, MD PhD, Department of Urology, Sapienza University of Rome, Italy, Viale del Policlininico, Roma, Italia. Email: constantino.leonardo@gmail.com Received 7 April 2008; accepted 16 September 2008. Online publication 22 April 2009 International Journal of Urology (2009) 16, 584–586 doi: 10.1111/j.1442-2042.2008.02209.x 584 © 2008 The Japanese Urological Association