Is salvage RP after focal therapy feasible?

A review of outcomes in patients with prostate cancer undergoing radical prostatectomy (RP) after focal therapy demonstrates feasibility of the salvage procedure, but also identifies issues that should be considered by urologists who will be performing the surgery and when counseling patients about focal therapy.

At the AUA annual meeting in San Francisco, Jaime O. Herrera-Caceres, MD, and colleagues from the Princess Margaret Cancer Centre, University of Toronto, presented findings from what they believe to be the largest single-center reported series of patients undergoing salvage RP after focal therapy. It included 34 men who underwent the salvage procedure because of biopsy-proven recurrence. All patients had low- or intermediate-risk prostate cancer before focal therapy.

The authors reported few intraoperative complications and that neurovascular bundle preservation was possible in over one-half of the cases (56%). However, there was difficulty performing the dissection where focal therapy had been done, and while functional outcomes were satisfactory, the oncologic outcomes (positive margins, PSA persistence, and biochemical recurrence) were not as good as after primary RP, said Dr. Herrera-Caceres, who worked on the study with Neil Fleshner, MD, MPH, and colleagues.

“Although it appears that salvage RP can be done after focal therapy and has acceptable functional and short-term oncologic outcomes, we believe it should be performed at experienced centers because it is a challenging procedure,” said Dr. Herrera-Caceres, noting that the findings are consistent with a multicenter study presented earlier in the year at the European Association of Urology annual congress in Copenhagen, Denmark.

He reported that biopsy-proven recurrence occurred within 1 year after focal therapy. At salvage RP, 59% of men were found to have locally advanced disease (pT3) and 38% of patients had positive surgical margins that were shown to increase the risk of PSA persistence and biochemical recurrence during a mean follow-up of 4.3 years.

Next:"For now, our findings should make urologists aware of the importance of early control biopsies following focal therapy"
“The rate of locally advanced disease and positive surgical margins after RP in a group of patients with initially low- or intermediate-risk disease is concerning and raises questions that warrant further study. For now, our findings should make urologists aware of the importance of early control biopsies following focal therapy,” Dr. Herrera-Caceres told Urology Times.

Nineteen (56%) of the men had undergone high-intensity focused ultrasound, 13 (38%) had laser ablation, and single patients each underwent cryotherapy or focal brachytherapy. Most of the focal therapy procedures were done with in-bore MRI guidance.

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The salvage RP was performed with an open technique in 82% of men. Intraoperatively, cystostomy occurred in two patients, but there were no rectal injuries.

Mean PSA at the time of surgery was 5.38 ng/mL, and nine patients (26%) had persistent PSA postoperatively. No patients died or developed metastases during follow-up after salvage RP. Six patients (18%) received adjuvant radiotherapy, six (18%) received salvage radiotherapy, and four (12%) received androgen deprivation therapy with or without radiotherapy. Nine patients (27%) developed biochemical recurrence at a mean of almost 3 years after salvage RP.

The review of functional outcomes showed 31 patients (91%) were continent, defined as needing ≤1 pad per day. Prior to RP, 58% of patients had some degree of erectile dysfunction and all patients had some degree of erectile dysfunction after the salvage procedure, but 53% were able to have intercourse using medical therapy.

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