One of the most common reasons I am given by patients choosing to have their prostate removed is the argument that one can do radiation after surgery but you can’t (easily) do surgery after radiation. It is a valid argument and I think something to consider in the decision-making process. The concept is, however, not that cut and dried. Here are some caveats.
- If you have your prostate removed and at some point your PSA goes up then that means there is residual disease. In most cases the disease is microscopic and local (near the bed from which the prostate was removed). In this case where there may be a very small amount of disease then external beam radiation can “clean up” the residual disease for a curative intent. An example would be may be a very small amount of prostate tissue was not resected at the time of a prostatectomy (at the apex of the prostate where it joins the urethra, or an area near the nerve bundles laterally), and in this case having the option of more treatment is a nice fall back option.
- The above differs from say seed therapy or radiation therapy that for some reason did not kill all the cells in the prostate proper. In this case the PSA would go up after treatment as well, but there would be no good surgical option.
- The problem with surgery after radiation has to do with the damage to the tissue planes that are used to safely remove the prostate and limit incontinence, bleeding , and potency. Surgeons refer to this scenario as working “in concrete.” The best time to do surgery is in “virgin” territory.
- More and more centers are doing “salvage prostatectomies” after failed radiation, however the expected increase rates of complications can be expected. I would think this type of patient places the attempt at cure to so great that he is willing risk the downside to hopefully be done with the cancer. He is a cure first type patient.
- Another issue with a salvage prostatectomy is that one assumes that the rising PSA is on the basis of prostate cancer only in the prostate. Our tests to prove that the prostate cancer is only in the prostate leave a bit to be desired and are not always accurate or definitive. I ordered a Prostascint scan recently and the report came back, ” a suggestion of prostate cancer in the lymph nodes.” I don’t think you’d want to go through a salvage prostatectomy and all that entailed only to be told six months later that the PSA is rising again.
- You can do cryotherapy after external beam therapy, you can do it after seeds but this is associated with a higher complication rate.
- If you have had your prostate removed, your PSA rises and in actuality the reason is for undetectable cancer in the pelvic lymph nodes and you then are a candidate for external beam therapy. The PSA will go down but that doesn’t mean that it will result in a cure. As a rule, in most cancers, if disease reaches the lymph nodes then you chances of cure go down. So in this scenario, you are able to follow surgery with radiation but it might not make a large difference in the long run.
So, the rationale for choosing surgery because you can do radiation later is a reasonable decision, but not one that will always make a difference in your ultimate outcome. I feel it does make a difference in the situations I mention above, but you really won’t know until you have the radiation and over an extended period of time your PSA goes down and never goes up again.
|Salvage Prostatectomy with Bladder Neck Closure, Continent Catheterizable Stoma and Bladder Augmentation: Feasibility and Patient Reported Continence Outcomes at 32 Months|
|Thursday, 12 July 2007|
|BERKELEY, CA (UroToday.com) – Although there is strong evidence to suggest that salvage prostatectomy or cryotherapy may cure a subset of patients with recurrent prostate cancer after radiation therapy these aggressive therapies cause substantial morbidity. The main long-term complication is urinary incontinence which is reported to occur in 45-80% of patients. This incontinence is often severe and refractory to treatment. Previous reports on salvage prostatectomy with bladder neck closure and continent catherizable stomas were troubled with persistent urgency, low capacities, and the need for frequent catherizations. Because of this, the addition of bladder augmentation to this procedure was entertained. A recent manuscript by E. De, O. L. Westney and colleagues from Albany Medical Center and M. D. Anderson Cancer Center in Houston reports on a series of patients with recurrent prostate cancer after radiation therapy that underwent salvage prostatectomy, bladder neck closure, bladder augmentation, and creation of catherizable stomas. The mean time to surgery after radiation was 61 months. Mean patient age at surgery was 59.5 years. The paper is published in the June 2007 issue of the Journal of Urology.Eleven patients underwent the above procedure with either catherizable appendicovesicostomy or Monti ileovesicostomy over a 2.5 year period. Self-reported outcome measures included patient questionnaires and the validated Incontinence Symptom Index. Mean follow-up was 32 months.
Analysis of the results showed that the physician noted that 8 of the 11 patients (73%) were dry. Nine of the 11 patients returned the questionnaire. Only 2 of these (22%) reported requiring pads for incontinence. Forty-four percent reported no leakage and only 3 (33%) reported leakage more frequently than once weekly. Three of the 11 (27%) required stomal revision at an average of 24 months, of whom 2 still reported difficult catherization. The mean catherization interval was 3.75 hours versus 2 to 6 hours in the previous series without the bladder augmentation. Seven of the 9 patients (77%) reported that they would repeat the procedure again. The authors report that 10 patients who underwent an attempt and salvage prostatectomy and urethral anastomosis during this time and this group had a 50% incontinence rate and a 40% bladder neck contracture rate.
Of the 11 patients, 3 progressed to metastatic disease, one of whom died. An additional 2 patients had biochemical recurrence that was responsive to hormonal therapy. The editorial comment by Victor Netti suggested that pre-operative urodynamic studies may help determine which patients require the added step of augmentation while undergoing this aggressive surgical management for recurrent prostate cancer after radiation therapy.
De E, Pisters LL, Pettaway CA, Scott S, Westney OL
J Urol. 177(6): 2200-4, June 2007