Preoperative PSA level correlated best with pathologic diagnosis
The patient must be fully informed and an active participant in the decision process, because complication from local salvage techniques may be substantial. It is important to mention that in the discussion of the salvage modalities outlined below, the information presented is primarily from series reporting the results from patients that have failed EBRT. There currently is a paucity of data on salvage treatment of brachytherapy failures. Salvage radical prostatectomy following brachytherapy failure Salvage radical prostatectomy for patients who have failed local RT remains a feasible option, yet one associated with potentially significant complications. Although there are no widely agreed on selection criteria, most surgeons who perform salvage prostate surgery choose patients carefully and fully inform them of the potential associated risks. Candidates for salvage prostatectomy must have a good performance status; the absence of significant medical comorbidities; a life expectancy exceeding 10 years; organ-confined disease by digital rectal examination, TRUS, or endorectal MRI; a low postimplant PSA level (<10 ng/mL); and favorable preimplant tumor parameters. Additionally, the patient should be relatively free of urinary or bowel symptoms, and, if not, an endoscopic evaluation to rule out radiation cystitis or proctitis should be considered. The patient also must be willing to accept the potential for postprostatectomy incontinence and impotence in the setting of prior radiation and the possibility of rectal injury, which may necessitate fecal diversion (colostomy) to allow the irradiated tissues to heal. It is therefore imperative that the patient be highly motivated and willing to accept the potential risks of salvage surgery in an effort to affect a cure. Although some authors have recommended an antegrade or combined abdominoperineal approach to salvage prostatectomy, most employ a standard radical retropubic prostatectomy technique with modest modifications. Pelvic lymph node dissection during radical prostatectomy for initial treatment of patients with low-risk disease often is omitted, whereas several large studies have demonstrated a low risk of nodal disease and no additional therapeutic benefit in this population. However, during salvage prostatectomy, a full pelvic lymph node dissection should be performed and frozen sections must be strongly 744 E.M. Horwitz et al / Urol Clin N Am 30 (2003) 737–750 considered, whereas positive nodes would signify extraprostatic disease. This possibility should be discussed with the patient preoperatively, since further attempts at salvage prostatectomy may be abandoned in the setting of node-positive disease. As with standard prostatectomy, the apical dissection must proceed in a meticulous fashion. Patients who have had brachytherapy may have adherence of the anterior surface of the prostate to the pubis or the posterior surface to the rectum, making dissection more tedious. If this is the case, sharp dissection is most appropriate and blunt dissection is to be avoided. In cases of salvage prostatectomy, nerve preservation is not advocated or feasible. Postoperative management should proceed in much the same manner as after a standard prostatectomy, yet with a more judicious concern with regard to the higher risk of bladder neck contractures following salvage surgery. Despite the willingness of most surgeons to consider postradiation salvage surgery, the collective published experience is relatively small and relates more specifically to failures of EBRT than to brachytherapy. The rate of pathologically organ-confined disease in most series is low and ranges from 5% to 36%, whereas the risks of rectal injuries (15%), bladder neck contractures, and urethral strictures (7%–28%) and severe urinary incontinence (23%–64%) are relatively high. In a contemporary series from Baylor Medical Center reporting on salvage prostatectomy, 40 patients with a mean radiation dose of 7194 cGy underwent salvage surgery an average of 58.9 months after radiation treatments. Thirty-one patients (78%) were found to have extracapsular or locally advanced disease, whereas only eight patients (20%) had tumor still confined within the prostate. Preoperative PSA level correlated best with pathologic diagnosis and cancer-specific outcomes. In another recent series reported from the Mayo Clinic, 108 patients undergoing salvage prostatectomy over a 20-year period were reviewed; of these, only two had received brachytherapy.