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Radikale Salvageprostatektomie bei lokalem Prostatakarzinomrezidiv nach Strahlentherapie

Funktionelle und onkologische Ergebnisse

Functional and oncological outcome of salvage prostatectomy of locally recurrent prostate cancer following radiation therapy

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Zusammenfassung

Hintergrund

Ein lokoregionäres Prostatakarzinomrezidiv entwickelt sich bei 30–50% der Patienten nach perkutaner oder interstitieller Strahlentherapie. Obwohl die radikale Salvageprostatektomie (SRPE) eine sekundäre lokale Therapieoption mit kurativer Intention darstellt, wurden in der Vergangenheit aufgrund der vermeintlich erhöhten therapieassoziierten Komplikationsrate nur wenige Patienten der operativen Behandlung zugeführt. Wir berichten über unsere Erfahrungen bezüglich der Morbidität und der onkologischen Ergebnisse nach SRPE.

Patienten und Methodik:

Zwischen 1/2003 und 8/2005 wurden 28 konsekutive Patienten der SRPE bei lokoregionärem Rezidiv eines Prostatakarzinoms (PCA) nach perkutaner dreidimensionaler (3D-)konformaler Bestrahlung (n=14), nach HDR-Brachytherapie (n=8) sowie nach LDR-Brachytherapie (n=6) unterzogen. Die Diagnose eines lokoregionären Rezidivs wurde durch transrektale Stanzbiopsie, CT Abdomen/Becken und Knochenszintigrafie präoperativ gesichert. In allen Fällen erfolgte eine retropubische SRPE mit pelviner Lymphadenektomie in aszendierender Technik. Nach einem mittleren Follow-up von 12,5 (2–29) Monaten erfolgte die Auswertung der Morbidität und der onkologischen Resultate.

Ergebnisse

Die SRPE erfolgte bei allen Patienten ohne signifikante Komplikationen, es traten keine Rektum- oder Ureterläsionen auf, der mittlere Blutverlust betrug 520 (200–950) ml. Die pathohistologische Analyse des Prostatektomiepräparats zeigte ein pT1-2b-PCA bei 19 (72%) Patienten, ein pT3b-PCA bei 5 (20%) Patienten, ein pTxpN1-PCA in 8,5%, einen R1-Befund in 8,5% sowie einen pT0-Befund in 7% der Patienten. 20% der Patienten wiesen einen Gleason-Score von 8–10 auf. Nach einem mittleren Follow-up von 12,5 Monaten wiesen 25% der Patienten eine Stressinkontinenz mit Verbrauch von 1–2 Vorlagen/Tag auf. Eine vesikourethrale Anastomosenstriktur entwickelte sich bei 12% der Patienten. 2/28 (7%) zeigen einen PSA-Progress bei primär lokal fortgeschrittenem Tumor.

Diskussion

Die SRPE ist eine lokale Therapiemaßnahme mit kurativer Intention zur Therapie des Lokalrezidivs eines PCA nach Strahlentherapie. Komplikationsraten und Morbiditäten sind gering und nicht mehr mit den Daten früherer Publikationen zu vergleichen. Die Indikationsstellung zur SRPE setzt eine sorgfältige Patientenidentifikation durch präoperative Stanzbiopsie und bildgebende Diagnostik voraus. Die SRPE sollte in das therapeutische Spektrum zur Therapie des Lokalrezidivs des PCA nach Strahlentherapie frühzeitig berücksichtigt und an erfahrenen Zentren durchgeführt werden.

Abstract

Background

Although technically challenging, salvage radical prostatectomy (SRP) for radiorecurrent prostate cancer (PCA) is an effective option in carefully selected patients and offers the chance for cure and long-term survival. Sometimes local progression of PCA with subvesical obstruction following radiation therapy requires radical cystoprostatectomy or bladder-preserving urinary diversion. We present our experience with salvage radical prostatectomy in a group of 28 consecutive patients.

Patients and methods

Between January 2003 and August 2005, 25 patients underwent radical salvage surgery for locally recurrent PCA following external beam radiation (n=14), high-dose brachytherapy (n=8), and low-dose brachytherapy (n=6). All men had biopsy-proved recurrent or persistent PCA associated with PSA progression following radiation therapy. Preoperative imaging studies included bone scintigraphy and computed tomography without evidence of metastatic disease. Of the 28 men, 11 (39%) presented with bothersome irritative voiding dysfunction and rectal discomfort. Life expectancy was >10 years in all cases. We analyzed preoperative symptoms, treatment-associated morbidity, pathohistological findings, and functional and oncological outcome after a mean follow-up of 12.5 (2–29) months.

Results

SRP was performed in all cases without significant intra- and perioperative complications: no rectal lacerations or ureteral lesions were encountered and mean blood loss was 520 (200–950) ml. A total of 21 (75%) men underwent SRP: in 4 cases radical cystoprostatectomy was necessary due to bladder neck infiltration and in 3 men SRP with bladder neck closure and continent appendicovesicostomy was performed due to preexisting urinary stress incontinence. All men with subvesical obstruction experienced significant relief of urgency and significant irritative voiding dysfunction following radical salvage surgery. Pathohistological analysis of the prostatectomy specimen revealed pT1–2b PCA in 19 (67.8%), pT3a/b PCA in 5 (17.8%), and lymph node metastasis or positive surgical margins in 7% of the patients. Two patients demonstrated a pT0 despite positive preoperative biopsies, and 20% demonstrated a Gleason score 8–10. With regard to functional outcome, 25% of the men need 2–3 pads daily whereas 78% of the men are continent. After a mean follow-up of 12.5 (2–29) months, two patients with pT3b and pN1 status exhibit a PSA relapse.

Conclusion

Salvage RP or RCx is a technically challenging but feasible surgical approach with curative intent for the treatment of locally recurrent PCA in well selected patients preventing significant local complications such as subvesical obstruction, ureteral obstruction, hematuria, and rectal infiltration. Surgery-associated morbidity and complications are low and not comparable to earlier series. The indication for salvage RP requires positive biopsy and negative imaging studies.

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  1. Sektion für Urologische Onkologie, Klinik und Poliklinik für Urologie, Universität Köln,

    A. Heidenreich, C. H. Ohlmann, E. Özgür & U. H. Engelmann

  2. Urologische Onkologie, Klinik und Poliklinik für Urologie, Universität, Joseph-Stelzmann-Straße 9, 50931, Köln

    A. Heidenreich

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  1. A. Heidenreich
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Correspondence to A. Heidenreich.

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Heidenreich, A., Ohlmann, C.H., Özgür, E. et al. Radikale Salvageprostatektomie bei lokalem Prostatakarzinomrezidiv nach Strahlentherapie. Urologe 45, 474–481 (2006). https://doi.org/10.1007/s00120-006-0995-9

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