Debulking surgery in the setting of very high-risk prostate cancer scenarios

Authors


Paolo Gontero, University of Turin, Urologia 1, A.O.U. San Giovanni Battista, C.so Bramante 88/90, 10126, Turin, Italy. e-mail: paolo.gontero@unito.it

Abstract

Study Type – Therapy (case series)

Level of Evidence 4

What's known on the subject? and What does the study add?

Nowadays radical prostatectomy (RP) is considered an effective treatment in high-risk prostate cancer (PCa) and the indications for a surgical approach are expanding, even in cases of very high PSA or node-positive disease. We explored the outcomes of debulking surgery in the setting of these very high-risk PCa patients, in order to assess its feasibility.

This review confirms the important role achieved by surgery in the complex setting of patients with very high-risk PCA. Excellent survival rates have been reported, even when PSA exceeds 100 ng/mL. The completion of RP with lymphadenectomy might give a survival benefit in patients who were found intraoperatively to be node-positive. Furthermore, salvage RP confirmed to be the most effective treatment option after RT failure. On the contrary, up-to-date surgery of isolated nodal recurrences has shown only little benefit. Finally, there is no evidence supporting the efficacy of debulking surgery in metastatic or in hormone-refractory tumours. An accurate selection of the patient is essential.

OBJECTIVE

  • • To conduct a critical analysis of the available literature on the feasibility of debulking surgery in the setting of very high-risk prostate cancer (PCa) scenarios.

PATIENTS AND METHODS

  • • We performed a systematic literature search of PubMed and Embase using combinations of the following keywords: radical prostatectomy, surgery, high-risk, high PSA (prostate-specific antigen), radiorecurrent, hormone-refractory, metastatic prostate cancer, salvage.
  • • With the term ‘very high-risk PCa’ we indicated a clinical disease beyond the common definition of high-risk PCa, i.e. any clinical stage > T3, N0 or N+, any PSA level > 50 ng/mL and any recurrent disease after primary treatment.

RESULTS

  • • Radical prostatectomy (RP) achieved excellent survival rates in high-risk PCa, even in patients with very high PSA level. The completion of RP with lymphadenectomy might give a survival benefit in patients who were found intraoperatively to be node-positive.
  • • Salvage RP was confirmed to be the most effective treatment option after radiotherapy failure, with increased functional outcomes and decreased side-effects in the most recent series.
  • • Surgery of isolated nodal recurrences after previous radical therapy has shown little benefit according to the few available series.
  • • There is no evidence supporting the efficacy of debulking surgery in metastatic or hormone-refractory PCa.

CONCLUSION

  • • Debulking surgery achieved an important role in several aggressive PCa scenarios. An accurate selection of the patient is essential.

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