The Role of Salvage Radical Prostatectomy in Patients with Radiation-Resistant Prostate Cancer

SIMPLE SUMMARY: Prostate cancer affects one out of every eight men over the course of their lifetimes, and recurrence of the disease after initial cancer treatment occurs in almost one-third of men. The aim of our review was to assess the role of salvage radical prostatectomy in patients with prostate cancer recurrence after initial treatment with radiotherapy. Outcome data demonstrate that radical prostatectomy has oncologic benefits, although it incurs several intraoperative and postoperative functional risks including rectal injury, erectile dysfunction, and incontinence. Given that there is no clinical consensus on which management approach is superior for patients with localized prostate cancer recurrence, this review provides evidence that radical prostatectomy offers meaningful cancer control and should be considered for select patients with radiation-resistant disease. ABSTRACT: There are multiple treatment strategies for patients with localized prostate adenocarcinoma. In intermediate- and high-risk patients, external beam radiation therapy demonstrates effective long-term cancer control rates comparable to radical prostatectomy. In patients who opt for initial radiotherapy but have a local recurrence of their cancer, there is no unanimity on the optimal salvage approach. The lack of randomized trials comparing surgery to other local salvage therapy or observation makes it difficult to ascertain the ideal management. A narrative review of existing prospective and retrospective data related to salvage radical prostatectomy after radiation therapy was undertaken. Based on retrospective and prospective data, post-radiation salvage radical prostatectomy confers oncologic benefits, with overall survival ranging from 84 to 95% at 5 years and from 52 to 77% at 10 years. Functional morbidity after salvage prostatectomy remains high, with rates of post-surgical incontinence and erectile dysfunction ranging from 21 to 93% and 28 to 100%, respectively. Factors associated with poor outcomes after post-radiation salvage prostatectomy include preoperative PSA, the Gleason score, post-prostatectomy staging, and nodal involvement. Salvage radical prostatectomy represents an effective treatment option for patients with biochemical recurrence after radiotherapy, although careful patient selection is important to optimize oncologic and functional outcomes.