Der Urologe

, Volume 45, Issue 10, pp 1260–1265

Salvage-radikale Prostatektomie

Leitthema

Zusammenfassung

Hintergrund

Nach perkutaner oder interstitieller Strahlentherapie entwickeln 30–50% der Patienten ein lokoregionäres Rezidiv des Prostatakarzinoms. Obwohl die radikale Salvage-Prostatektomie (SRPX) eine sekundäre Therapieoption mit kurativer Intention ist, haben bislang weltweit nur wenige 100 Patienten von dieser Therapieoption Gebrauch gemacht. Gegenstand dieser Arbeit ist eine Übersicht über die Weltliteratur im Hinblick auf Frequenz, Technik, Erfolgsaussichten und Komplikationen dieser operativen Maßnahme.

Patienten und Methodik

Die Rate positiver Biopsien nach Strahlentherapie beträgt ungefähr 30%. Dennoch wurden bis 2005 in der Weltliteratur nur 536 Fälle von Salvage-RPX nach Strahlentherapie mitgeteilt. Die Diagnose des Lokalrezidivs wurde immer durch transrektale Stanzbiopsie, Becken-CT und Knochenszintigraphie gesichert. Als operative Therapie wurden Salvage-RPX ± „nerve sparing“ mit pelviner Lymphadenektomie bis hin zur Zystovesikuloprostatektomie mit Harnableitung angewandt.

Ergebnisse

Prädiktoren einer erfolgreichen Zweitbehandlung nach Strahlentherapie sind Gleason-Score, PSA und jüngeres Alter, nicht aber das klinische Stadium und die Art der Erstbehandlung. Das progressionsfreie Überleben nach 5 Jahren beträgt für die Stadien pT2, pT3a und pT3b/pN1 77%, 71% beziehungsweise 28%. Damit ist die Salvage-RPX für identische Stadien gleichermaßen erfolgreich wie eine De-novo-RPX. Die Salvage-RPX stellt die optimale lokale Salvage-Therapie dar. In der Vergangenheit waren die Komplikationen nach Salvage-RPX wegen Strahlentherapie beträchtlich. Im Durchschnitt der Weltliteratur fanden sich 6,5% Rektumläsionen, 17% Anastomosenstrikturen und eine Inkontinenzrate von 50%. Die Indikation für eine Salvage-Zystovesikuloprostatektomie mit Harnableitung besteht bei einem lokal fortgeschrittenen Tumor (Blasenhals, Rektum), bei Vorliegen einer hämorrhagischen Strahlenzystitis, einem simultanen Harnblasenkarzinom oder einer defunktionalisierten Blase.

Folgerungen

Eine Salvage-RPX ist eine radikale Prostatektomie mit kurativer Intention nach Bestrahlung mit ebenfalls kurativer Intention. Die Gründe für die Seltenheit der Salvage-RPX sind: 1) onkologische Bedenken (zu lange Beobachtung des PSA-Verlaufs durch den Strahlentherapeut/Onkologe/Urologe) und 2) chirurgisch-technische Bedenken wegen einer technisch herausfordernden komplikationsträchtigen Operation mit dem Schwerpunkt Inkontinenz. Bei korrekter Indikation ist die Comorbidität in jüngerer Zeit akzeptabel. Die Lebenserwartung des Patienten sollte größer 10 Jahre betragen, die positive Stanze mindestens 1 Jahr nach Ende der Strahlentherapie erfolgt sein und initial sowohl vor der Bestrahlung als auch vor der Salvage-RPX ein Stadium T1/2 des Prostatakarzinoms vorliegen. Vor der Ersttherapie als auch vor der Salvage-RPX sollte der PSA-Wert <10 betragen. Eine hohe Patientenmotivation mit Akzeptanz der chirurgischen Morbidität (50% Inkontinenz!) sollte gegeben sein.

Schlüsselwörter

Lokal begrenztes Prostatakarzinom Strahlentherapie Lokalrezidiv PSA-relaps Salvage-RPX 

Salvage radical prostatectomy

Abstract

Background

Following external beam radiation and interstitial radiation for prostate cancer, between 30% and 50% of the patients experience locoregional recurrence of their cancer. Although radical salvage prostectomy is a secondary treatment option with curative intent, so far only a few hundred patients (<2%) worldwide have undergone this operation. The subject of this paper is a review of the world literature with reference to the freqency with this operation is performed and the technique, and also the prospects of success and possible complications.

Patients and methods

After radiotherapy, approximately 30% of biopsies are positive. Nonetheless, only 536 cases of salvage radical prostectomy had been reported in the world literature up to 2005. The diagnosis of a local recurrence was always confirmed by rectal punch biopsy, pelvic CT and bone scintigraphy. Salvage radical prostatectomy with or without nerve sparing, with pelvic lymphadenectomy and, in some patients with cystectomy plus urinary diversion was the operative treatment applied.

Results

Following secondary treatment after radiotherapy (RT), three parameters have been consistently identified as predictors of local failure: PSA nadir, time to nadir and PSA doubling time; clinical stage and type of first-line treatment are not helpful in predicting failure. The 5-year biochemical relapse-free survival rates are 77%, 71% and 28% for stages pT2, pT3a and pT3b/pN1, respectively. The success rate for salvage radical prostectomy is thus similar to that for de novo radical prostatectomy for the same stages. In the past salvage radical prostatectomy following radiotherapy had a high complication rate.

Conclusions

A salvage radical prostatectomy with curative intent is a radical prostatectomy following radiotherapy also performed with curative intent. The reasons for the few literature reports of salvage RPX are: (1) oncological misgivings (too long a period of observation of PSA by the radiation oncologist/urologist; (2) misgivings to do with surgical technique, as the operation is technically challenging and involves a high risk of complications, especially incontinence. In recent times the comorbidity rate has become acceptable in cases in which the indications have been correctly observed. We believe that salvage prostatectomy should be considered only for patients in good general health whose life expectancy is over 10 years and who have recurrent cancer confirmed by punch biopsy 1 year or longer after the completion of radiotherapy and whose cancer was initially in an early (T1–2) clinical stage before their radiotherapy. Ideally, serum PSA should be less than 10 ng/ml both initially (before radiotherapy) and before salvage surgery. In addition, patients should be highly motivated and able to accept the surgical morbidity (50% incontinence rate).

Keywords

Localized prostate cancer Radiation therapy Local recurrence PSA relapse Salvage radical prostatectomy 

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Copyright information

© Springer Medizin Verlag 2006

Authors and Affiliations

  1. 1.Urologische Universitätsklinik UlmUlmDeutschland

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