Research Article
Salvage Robotic Prostatectomy after Brachytherapy
Fajardo-Paneque Marta*, Congregado-Ruiz Belén, Conde-Sánchez Jose Manuel and Medina-López Rafael Antonio
Department of Urology, Virgen del Rocío Universitary Hospital, Spain
*Corresponding author: Fajardo-Paneque Marta, Department of Urology, Virgen del Rocío Universitary Hospital, Manuel Siurot Avenue, 41013-Seville, Spain
Published: 28 Sep, 2016
Cite this article as: Fajardo-Paneque M, Congregado-Ruiz B, Conde-Sánchez JM, Medina-López RA. Salvage Robotic Prostatectomy after Brachytherapy. Clin Oncol. 2016; 1: 1104.
Abstract
Introduction: Salvage radical prostatectomy, although still underused, is becoming a feasible
treatment for young, healthy patients with biochemical progression after initial treatment with
radiotherapy. We introduce the first Spanish serie of salvage prostatectomies after low-dose rate
brachytherapy and it constitutes the first comparative serie between open and robotic surgery at a
single institution.
Materials and Methods: Descriptive and comparative study of fifteen patients who underwent
salvage radical prostatectomy between December 2009 and May 2014. 8 patients underwent open
surgery and 7 underwent robotics.
We analyzed and compared clinical and oncologic parameters at diagnosis and at relapse (PSA,
Gleason, clinical stage, time to progression), peri-operative complications, functional data and
oncologic outcomes.
Results: Median follow-up: 29.75 months in open prostatectomy and 11.29 in robotic one. The
complication rate was higher in the open surgery group (50 vs. 28.5%).
Four patients (26.7%) had postoperative persistent disease, three of them in the robotic group.
In multivariable analysis we found no association between positive surgical margins (PSMs) and
persistence of disease.
None PSA recurrence has been detected. There has been no exitus until date.
The percentage of incontinence is higher in the open surgery group (62.5 vs. 42.9%), while sexual
function is more affected in the robotic one.
Conclusions: We observed a higher percentage of locally advanced disease in robotic surgery
patients, associated with an increase in positive surgical margins in this group (p=0.01). PSMs were
not related to PSA persistence.
A trend to a greater rate of complications was seen in open surgery.
Keywords: Salvage radical prostatectomy; Salvage robotic-assisted laparoscopic prostatectomy; Prostate neoplasm; Brachytherapy; Biochemical progression
Abbreviations
EBRT: External Beam Radiotherapy; SRP: Salvage Radical Prostatectomy; HIFU: High Intensity Focused Ultrasound; SORP: Salvage Open Radical Prostatectomy; sRALP: Salvage Robotic-Assisted Laparoscopic Prostatectomy; PSA: Prostate-Specific Antigen; CT: Computerized Tomography; PET/CT: Positron Emission Tomography/Computerized Tomography; BMI: Body Mass Index; PSM: Positive Surgical Margin; PDE5Is: Phosphodiesterase Type 5 Inhibitors
Introduction
We report the first Spanish series of salvage radical prostatectomy following low-dose rate
brachytherapy. This is also the first publication analysing a homogeneous series of patients receiving
exclusively low-dose rate brachytherapy as primary radical treatment. Moreover, this is the first
study comparing the outcomes of open salvage radical prostatectomy and those of robotic-assisted
radical prostatectomy in a single institution.
According to the literature, 27% to 35% of patients with organ-confined prostate cancer
undergoing radical prostatectomy, External Beam Radiotherapy (EBRT) or brachytherapy with
curative intent, will experience biochemical progression within 10 years of receiving initial treatment. 16% to 35% of these patients will require second-line therapy during the first 5 years [1].
These second-line or salvage therapies have been progressively
developed and improved during recent years and nowadays there is
a variety of options at our disposal: Salvage Radical Prostatectomy
(SRP), salvage radiotherapy, brachytherapy (in patients treated with
EBRT), salvage cryotherapy, surveillance and high intensity focused
ultrasound (HIFU) [1].
Androgen deprivation therapy is another treatment to be
considered. However, it is increasingly indicated for ageing patients
or for patients whose high comorbidity does not allow the use of
salvage treatments [2,3].
As regards patients undergoing low-dose rate iodine-125
brachytherapy as initial treatment for low risk localized prostate
cancer, according to D'Amico risk-classification system 1998 [4], the
latest revisions of the literature show disease-free survival rates of 91-92% at 5 yrs and of 81% at 10 yrs [5,6].
Salvage radical prostatectomy, although still underused, is
becoming a feasible treatment for young, healthy patients who
present with biochemical progression after initial treatment with
radiotherapy, and there is ever more evidence in the literature
supporting its indication [3,7-10]. One of the latest issues of the
European Association of Urology Guidelines (EAU, March 2016)
rates salvage radical prostatectomy with a B recommendation grade
in selected patients. Likewise, due to the complexity and morbidity
associated with this technique, SRP is recommended to be performed
in experienced institutions (A recommendation grade) [1].
Open surgery has been traditionally the standard approach, but
robotic-assisted laparoscopic prostatectomy is gaining increasing
support given the lower perioperative morbidity and the shorter
hospital stay. Early oncological outcomes are promising, with diseasefree
survival rates similar to those obtained by means of open surgery.
Yet, it is necessary to carry out further prospective studies with longer
follow-up periods than those of the series so far published [7,8,10-13].
The aim of our study is to revise our series of salvage radical prostatectomies following low-dose rate iodine-125 brachytherapy
with curative intent in patients with low-risk localized prostate cancer.
We also compare Salvage Open Radical Prostatectomy (SORP)
with salvage robotic-assisted laparoscopic prostatectomy (sRALP)
in terms of functional and oncological outcomes and surgical
complications.
Materials and Methods
Descriptive and comparative observational study of 15 patients
undergoing salvage radical prostatectomy due to local recurrence after
early curative treatment with low-dose rate iodine-125 brachytherapy,
carried out from December 2009 to May 2014. Disease recurrence
was confirmed by means of transrectal ultrasound-guided prostate
biopsy due to the presence of biochemical progression.
Biochemical progression is defined according to the criteria
established by the American Society for Therapeutic Radiology and
Oncology (ASTRO) in the Phoenix Consensus Conference of 2005:
a rise of 2ng/mL or more above the PSA nadir in two consecutive
measurements obtained at least one month apart [14].
Prior to surgery, distant metastasis was discarded by means of bone scintigraphy and contrast enhanced thoracoabdominal and
pelvic CT scan. Recently, a new tool has been incorporated into our
diagnostic repertoire, the choline PET/CT. To the end of our study
this tool had been used in 6 patients, 4 included in the SORP group,
with negative results, and 2 other patients who were excluded from
the study due to the presence of metastasis and who consequently
could not be eligible for salvage surgery.
Patients were selected following the criteria established by
the EAU [1]: patients with low comorbidity, at least 10 yrs of life
expectancy, organ-confined disease p ≤T2b, Gleason ≤7 and PSA
<10ng/mL at recurrence.
Eight patients underwent retro pubic radical prostatectomy and
7 patients Da Vinci assisted laparoscopic radical prostatectomy. The
selection of the robotic arm is based upon the contraindications
established by the internal protocol of our service for robotic-assisted
surgery: BMI >35 kg/m2, previous intra-abdominal surgery, anesthetic
complications that contraindicate laparoscopy. All the interventions
have been performed by the two same urologists.
Robotic-assisted surgery does not differ from radical
prostatectomy as primary treatment, using the standard six-port
transperitoneal technique. However, being oncological control
our main aim, no intended nerve-sparing procedures have been
performed.
The preoperative preparation of patients for salvage prostatectomy
and primary radical prostatectomy does not differ, with the exception
of bowel preparation.
All the patients treated with robotic-assisted prostatectomy
underwent cystography prior to withdrawal of the urethral catheter
12 ± 3 days after the intervention. Whenever urinary leak was
observed, patients underwent a new cystography seven days later.
Postoperative follow-up has been carried out according to our
protocol: first revision one month after surgery including PSA test,
flowmetry, IPSS, urinary incontinence questionnaires (ICIQ) and
erectile function questionnaires (IIEF).
All biopsies and surgical specimens were analysed by the same
anatomopathologist specialized in uropathology.
The following clinical and oncological parameters have been
analysed and compared, both at diagnosis and at recurrence: PSA,
Gleason score and tumour stage at diagnosis and at recurrence, time
to biochemical progression, presence of bounce phenomenon.
We have analysed surgical complications, using Clavien-Dindo
classification [15], length of hospital stay and other perioperative
parameters that will be explained in more detail below.
We have also analysed the anatomopathological characteristics
and oncological outcomes: disease persistence and recurrence after
surgery, Gleason score, surgical specimen staging and time free of
biochemical progression in both groups.
PSA persistence is defined as a first postoperative PSA ≥0.1 ng/
mL; PSA recurrence as a post-treatment PSA ≥0.2 ng/mL, confirmed
by another consecutive PSA >0.2 ng/mL.
The following functional parameters have also been compared:
erectile function (erections sufficient for intercourse) and
postoperative urinary incontinence (mild, moderate or severe
incontinence depending on the daily use of pads).
SPSS Statistics v22 has been used to perform the statistical analysis
of data. A value of p <0.05 was considered as statistically significant.
Table 1
Table 2
Table 3
Table 4
Results
A total of 256 brachytherapies have been carried out in our
institution from January 2007 to May 2014. 9.8% of the patients
(25 patients) present with biochemical progression histologically
confirmed. 15 salvage prostatectomies have been performed to the
end of the present study.
Median follow-up period in the salvage open radical
prostatectomy group (SORP) was 29.75 months (11.5-54) vs. 11.29
months (2-19.5) in the salvage robotic-assisted prostatectomy group
(sRALP). The difference is explained by the fact that the roboticassisted
laparoscopic prostatectomy programme was implemented in
our institution in October 2012. As a result, the follow-up period in
this group is shorter.
Clinical and oncological parameters at diagnosis and at recurrence
Table 1 shows the clinical and oncological characteristics at
diagnosis and at recurrence. These variables are compared in both
groups. Median age at surgery was 62.88 yrs (59-68) in the first group
and 61.14 yrs (55-70) in the second group.
Most patients presented with T1c stage at diagnosis (73.3%) and
at recurrence (100%). Gleason score in the majority of cases was 3+3 (73.3% at diagnosis, 46.67% at recurrence, as observed in the
preoperative biopsy). In 5 patients (33.3%) Gleason score could not
be obtained at recurrence due to the effects of radiation. Median PSA
in both groups at diagnosis was 7.7 ng/mL (4.7-9.97). Median PSA at
recurrence was 4.56 ng/ mL (2.88-7.26). The Table shows the variables
distributed per groups, observing statistically significant differences
as regards PSA level at initial diagnosis of the tumour.
Median time to recurrence was 26.93 months (16-47), being
longer in the sRALP group, 31.57 months vs. 22.88 months in the
SORP group (p= 0.028). PSA bounce phenomenon was not observed
in any of the 15 patients.
Perioperative factors
Table 2 provides the perioperative factors under analysis. 25%
of the patients in the SRP group underwent bilateral limited pelvic
lymph node dissection vs. 57.1% of the patients in the sRALP group.
Nowadays, this technique is performed in all salvage prostatectomies.
The average number of ganglia obtained was 7.6 (4-13), being positive
in 2.6% (a single ganglion).
Mean hospital stay was slightly shorter in the robotic-assisted
surgery group (4.6 vs. 6.6 days), without statistical significance.
The complications observed using Clavien-Dindo classification
were more common in the open surgery group, showing a tendency
towards significance. Yet, larger series of patients would be necessary
to confirm such tendency.
Patients in the SORP group presented with three minor
complications: two surgical wound seromas (Clavien I) and one
surgical site abscess (Clavien II), which resolved with antibiotics.
We also observed a major complication: rectal injury during surgery
which required temporary ileostomy diversion (Clavien IIIb).
Patients in the sRALP group presented with two minor
complications: one acute epididymitis (Clavien II) and one urinary
infection with acute bladder retention (Clavien II). No major
complications occurred.
The incidence of ureterovesical anastomosis leak is similar in
both groups, 37.5% in the first vs. 33.3% in the second group. In both
groups the leak was treated with prolonged catheterization. A single
anastomotic stenosis occurred in the open surgery group requiring
endoscopic internal urethrotomy.
Anatomopathological characteristics and oncological outcomes
Table 3 reports the oncological outcomes following salvage
surgery. Both Gleason score and disease staging (T) have progressed
in comparison to initial biopsy. All the tumours found in the surgical
specimen are bilateral and Gleason score 3+3, the most common
score both at diagnosis and recurrence, has been reduced to 40%.
In the first group, the percentage of low risk Gleason (3+3) reaches
62.5% vs. 14.3% in the sRALP group, without statistical significance.
A higher percentage of advanced disease (T3a+T3b) is observed
in the robotic-assisted surgery group: 71.4% in the sRALP group vs.
12.5% in the SORP group, with a statistically significant p=0.04.
As a result, a higher incidence of extra capsular extension is
observed in the robotic-assisted surgery group (71.4% vs. 12.5%,
p=0.04) and greater seminal vesical invasion. Consequently, we find
a greater incidence of positive surgical margins in this group (85.7%
vs. 12.5%, p <0.01).
Four of the total number of patients (26.7%) present with
postoperative persistence disease, three of them in the sRALP group,
without statistical significance. These patients are treated with
adjuvant hormonal therapy, free of progression disease at present.
The multivariate analysis does not reveal correlation between PSMs
and PSA persistence. To date, no recurrences or exitus have occurred
in our series.
Functional outcomes
In Table 4 we can see the functional outcomes.
No significant differences are observed between the two groups
as regards urinary incontinence. 33.3% of the patients present with
adequate urinary continence (0-1 pads/day) and 53.3% present with
severe incontinence (>3 pads/day). Three of the patients with severe
incontinence are in the robotic-assisted surgery group, which has a
shorter follow-up period, thus the results are expected to improve.
One of the 5 patients in the SORP group required implantation of an
artificial urinary sphincter and another patient required placement of
Argus sub urethral sling.
In relation to erectile function, we must bear in mind that the
incidence of erectile dysfunction prior to surgery was 50% in the
SORP group and 57.14% in the sRALP group. We lack data about
previous erectile function in two patients of the first group and in one
patient of the second group. In two patients of the second group, the follow-up period is too short to obtain significant outcomes.
50% of the patients in the SORP group attain erections sufficient
for penetration with the help of phosphodiesterase Type 5 inhibitors
(PDE5Is) vs. 14.3% of patients in the sRALP group. However, all
patients who do not respond to oral treatment have shown positive
response to intra-cavernous injections of prostaglandin.
Discussion
The first report of a salvage radical prostatectomy (SRP) dates
from 1980 and was performed by Carson et cols [16].
Traditionally underused, this technique presents a challenge
to the urologist because of its greater complexity in comparison to
primary radical prostatectomy and the higher comorbidity associated
to it, which in part explains its scarce use [8,11,17]. The series
published in the last decade show better outcomes associated with the
earlier diagnosis of recurrence, the surgeon's experience [9] and the
improvement in radiotherapy techniques [18].
We must mention that to date, all the series published report
the outcomes in patients treated with different techniques with
curative intent (radiotherapy, brachytherapy, radiotherapy and
brachytherapy, cryotherapy, etc). As a result, these patients will
belong to different risk groups, according to D'Amico, and will have
different prognosis and probability of recurrence. We have not found
any series in the literature focusing exclusively on low-risk patients
initially treated with low-dose rate brachytherapy, as is the case of our
series. Likewise, we have not found any series of a single institution
comparing the outcomes obtained by means of open surgery with
those of robotic-assisted laparoscopy. Our series is the first Spanish
series with these characteristics.
It is difficult to make generalizations as regards the oncological
outcomes of the different series due to the variety of definitions given
to the terms recurrence and biochemical progression; to the variation
in follow-up periods, normally too short; to the limited number of
patients included in the series and to the heterogeneity of the series
which include different risk groups.
Recently, the review of the literature on salvage radical
prostatectomy (SRP), including all the surgical techniques, published
by Chade [9] has shown 5-year survival rates free of biochemical
progression ranging from 47% to 82% and 10-year rates which range
from 28% to 53%. Cancer-specific survival at 10 yrs reaches 70% to
83% and global survival at 10 yrs, 54% to 89%. The first series of 7
patients undergoing radical laparoscopic prostatectomy (RLP) was
published in 2003 [19] and more recently, in the series of 15 patients
published by Ahallal [20], this technique is presented as a feasible,
fairly safe treatment with oncological outcomes similar to those of
open surgery. Nevertheless, at present, salvage open prostatectomy
remains the gold standard.
In 2008, the first salvage robotic-assisted radical prostatectomy
was carried out [21]. In a review of 2013, Wheterell et al. [10] studied
the present role of this technique and reach the conclusion that it is
a feasible option which reduces perioperative morbidity and yields
functional and oncological outcomes similar to those of open surgery.
The same conclusions are expounded by Williams et al. [13].
The advantages of robotic-assisted surgery are, first of all the
3D vision [3,7,8,10,22-25] which allows for a better identification of
the planes of dissection, especially the posterior plane usually more adhered in patients receiving previous radiotherapy. This reduces the chances of injuring the rectum.
In our early experience we have also noted the especial difficulty
entailed by the dissection of this plane in comparison to primary
radical prostatectomy.
Secondly, the pneumoperitoneum reduces intraoperative blood
loss, being the estimated median blood loss 75-280 mL in comparison
to SORP, with a median blood loss of 690 mL. [10,22- 24].
Moreover, the robotic approach reduces considerably the length
of hospital stay, being of 1 to 2.7 days in the series published [3,10],
shorter than in our series (mean hospital stay of 4.6 days).
As regards oncological outcomes, some authors claim that they
are similar to those of open surgery. However, we must take into
account that the follow-up periods in these series are shorter than
in open surgery, the same as the number of patients included in the
series. As a result, this affirmation should be considered carefully
[11,17].
The largest series of patients undergoing robotic-assisted surgery
with the longest follow-up period published so far, is the one
reported by Yuh et al. [3]. They studied 51 patients with a median
follow-up period of 36 months, fairly superior to the others series in
the literature (around 16 months). In this series, 3-year survival rate
free of recurrence or biochemical progression, with independence
of prognostic risk, reached 57%. 25% of low risk patients, according
to D'Amico classification, presented with disease recurrence or
biochemical progression. Globally, 50% of the patients showed T3
stage tumours and 6% presented with ganglia involvement. The
incidence of positive surgical margins (PSMs) was 31%.
In the review by Wheterell et al. [10], global PSMs incidence was
24.7% and the incidence of biochemical progression was 24.7%.
In our series, we observe a high incidence of PSMs in the sRALP
group, 85.7%. This can be explained by the high incidence of extra
capsular extension in our series (71.4%). And in our opinion it is also
associated with the surgeon's learning curve. More positive outcomes
are found in the group of patients undergoing open surgery: PSMs
incidence of 12.5% in a group of patients with 12.5% of extra capsular
extension.
Despite the high percentage of PSMs in the sRALP group, PSA
persistence only reaches 42.9%, without recurrences to this date.
Therefore, the presence of PSMs does not necessarily indicate PSA
persistence. In fact, no statistical correlation has been found in our
series, which agrees with the reports of other authors.
For instance, in the Chauhan series of 15 patients, 4 (28.6%)
presented with biochemical progression and none of them showed
PSMs or ganglia involvement [26]. Kaffenberger, in a multivariate
analysis, did not find any correlation between PSMs and biochemical
progression either. However, he found correlation between apical
margin involvement and biochemical progression [8]. In the
multivariate analysis by Yuh et al. [3] no correlation was observed
between PSMs and disease recurrence.
The impact of PSMs on survival has not been reported by any
study.
A common finding in the published series is the high incidence of
locally advanced disease revealed by the pathological analysis of the surgical specimen.
Kaffenberger reports up to 47% of tumours ≥pT3. The same is
observed in the series analysed by Yuh, with an incidence of 50%.
In our series, we observe a 40% global rate of locally advanced
disease, which agrees with previous publications.
We must point out that when we analyse separately the two groups
included in our series, patients undergoing sRALP show 71.43% of
p ≥T3 tumours whereas such percentage reaches only 12.5% in the
SORP group (p=0.04). Although inclusion criteria are the same in
both groups, we could explain the difference by the fact that the lower
perioperative morbidity of robotic-assisted surgery makes it a valid
option for patients who in the past would not have been operated
with this technique.
In our series we observe progression both in Gleason score and in
tumour staging when compared with initial biopsy. All the tumours
found in the surgical specimen are bilateral and the percentage of
Gleason 3+3, the most common at diagnosis and found in 73.3% of
the patients, decreases to 40% when we analyse the surgical specimen.
This seems to be associated with the well-known under staging of
radical prostatectomy specimens, ranging from 25% to 30% [27] as
well as with the growth of radio-resistant tumours in some patients
[28].
The systematic use of 3D magnetic resonance imaging would
allow a more accurate locoregional staging [3].
Due to the difficulty to differentiate between local and distant
recurrence, new imaging techniques are being implemented such as
choline PET/CT scan. The utility of this method to assess biochemical
progression with curative intent is supported by European, American
and NCCN guidelines, which indicate its use for this purpose [1,
29,30].
In our institution, the systematic use of choline PET/CT has
been implemented recently for patients with histologically confirmed
recurrence and negative thoracoabdominal CT scan and bone
scintigraphy.
Regarding the most common perioperative complications, in the
series of patients undergoing open surgery reported before the year
2000, the rectum injury rate ranges from 0% to 28%. In the series
reported after the year 2000, such complication ranges from 2% to
10%, which agrees with the incidence observed in our series (6.6%).
Anastomotic stenosis reaches 7-27.5% in the series published before
2000 and 11-41% in subsequent series [9,12,31]. Such incidence is
lower in our series (6.6%).
In the series of patients undergoing robotic-assisted surgery so
far reported, the incidence of rectum injury ranges from 0% to 9%.
9% to 33% of patients present with anastomotic stenosis and the same
percentage of patients show anastomotic leak [9,22-25]. No serious
complications (Clavien ≥4) are described, with the exception of the
series studied by Yuh, where we find two cases of urological sepsis
(Clavien 4) [3,10,12]. Non-urological complications are very scarce
[8,26] and all of them are classified as Clavien 2.
In our robotic-assisted surgery group, the incidence of
complications is inferior to that reported in the literature, as we
mentioned earlier. No serious complications (Clavien ≥4), injury of
the rectum or anastomotic stenosis have been detected.
As regards functional outcomes, we must take into account that
our series present with a high percentage of erectile dysfunction and/
or urinary incontinence before surgery as a side-effect of primary
treatment. There are reported from 9% to 50% of patients who were
potent before surgery, depending on the series. Following surgery,
this percentage drops to 0-20% and up to 80% of the patients will
require treatment to maintain erectile function [10].
Variable urinary continence rates are described in the different
groups, ranging from 0% to 90% [3,9,10]. No differences are observed
between the series of patients undergoing open and robotic-assisted
surgery [8], but we find some series of patients undergoing roboticassisted
surgery with a lower incidence of urinary continence,
probably due to the shorter follow-up period in this group, as some
authors have already proposed [3,8].
Our results agree with the literature, but we must bear in mind
that the incidence of urinary continence in our series is slightly low,
mainly due to the short follow-up period in some patients.
So, although perioperative morbidity has been reduced in recent
years as a result of the most adequate selection of patients at highvolume
institutions, functional outcomes are still poor.
To summarize, in this paper we provide our experience in open
and robotic salvage prostatectomy, showing results consistent with
literature. Just emphasize that we have observed a higher incidence
of extra capsular disease in the robotic group related to a greater
incidence of positive surgical margins, with no impact on survival or
disease recurrence. Moreover, our rate of complications is lower than
the literature, being higher at the open surgery group.
We can conclude that oncological outcomes of salvage roboticassisted
prostatectomy are promising and similar to open surgery.
The perioperative morbidity is lower, leading to a greater number of
patients eligible for salvage surgery. This allows offering our patients
a potentially curative treatment.
The main limitation of our study is the small sample size. Another
disadvantage is the short follow-up period in patients undergoing
robotic-assisted surgery, which reduces the reliability of functional
and oncological outcomes.
A further limitation is the loss of data concerning the functional
outcomes of some patients.
Conclusions
We have detected a greater incidence of advanced disease in
the group of patients undergoing robotic-assisted surgery, which is
associated with an increase in positive surgical margins in this group
(p=0.01). PSMs are not related to PSA persistence in our study.
Open surgery shows a higher incidence of complications, but
series size should be larger to obtain significant results.
Early outcomes are promising but larger series of patients and
more long-term outcomes are required to confirm these results.
Acknowledgement
We would like to thank the Radiotherapy and Radio physics Services of Virgen del Rocío Universitary Hospital, which collaborate in performing the brachytherapy technique. In particular, to doctors Cabrera P, Jiménez MJ and Baeza M.
References
- Mottet N, Bastian PJ, Bellmunt J, Briers E, Bolla M, Cornford P, et al. Members of the European Association of Urology (EAU) Guidelines Office. Guidelines on Prostate Cancer. In: EAU Guidelines, edition presented at the 31th EAU Annual Congress, Munich 2016. ISBN 978-90- 79754-98-4.
- Agarwal PK, Sadetsky N, Konety BR, Resnick MI, Carroll PR. Treatment failure after primary and salvage therapy for prostate cancer: likelihood, patterns of care, and outcomes. Cancer. 2008; 112: 307-314.
- Yuh B, Ruel N, Muldrew S, Mejia R, Novara G, Kawachi M, et al. Complications and outcomes of salvage robot-assisted radical prostatectomy: A single-institution experience. BJU Int. 2014; 113: 769– 776.
- D’ Amico AV, Whittington R, Malkowic SB, Fondurulia J, Chen MH, Tomaszewski JE, et al. The combination of preoperative prostate specific antigen and postoperative pathological findings to predict prostate specific antigen outcome in clinically localizad prostate cancer. J Urol. 1998; 160: 2096-2101.
- Rodrigues G, Yao X, Loblaw A, Brundage M, Chin JL. Low-dose rate brachytherapy for patients with low- or intermediate- risk prostate cancer: a systematic review. Can Urol Assoc J. 2013; 7: 463-470.
- Alicikus ZA, Yamada Y, Zhang Z, Pei X, Hunt M, Kollmeier M, et al. Ten-year outcomes of high-dose, intensity-modulated radiotherapy for localized prostate cancer. Cancer. 2011; 117: 1429–1437.
- Kaffenberger SD, Smith JA. Salvage robotic radical prostatectomy. Indian J Urol. 2014; 30: 429–433.
- Kaffenberger SD, Keegan KA, Bansal NK, Morgan TM, Tang DH, Barocas DA, et al. Salvage robotic assisted laparoscopic radical prostatectomy: A single institution, 5-year experience. J Urol. 2013; 189: 507–513.
- Chade DC, Eastham J, Graefen M, Hu JC, Karnes RJ, Klotz L, et al. Cancer control and functional outcomes of salvage radical prostatectomy for radiation-recurrent prostate cancer: a systematic review of the Literature. Eur Urol. 2012; 61: 961–971.
- Wetherell D, Bolton D, Kavanagh L, Perera M. Current role of salvage robotic-assisted laparoscopic prostatectomy. World J Urol. 2013; 31: 463-469.
- Meeks JJ, Eastham JA. Robotic salvage prostatectomy: underused but not for the experienced. J Urol. 2013; 189: 413-414.
- Rocco B, Cozzi G, Spinelli MG, Grasso A, Varisco D, Coelho RF, et al. Current status of salvage robot-assisted laparoscopic prostatectomy for radiorecurrent prostate cancer. Curr Urol Rep. 2012; 13: 195–201.
- Williams SB, Hu JC. Salvage robotic assisted laparoscopic radical prostatectomy: indications and outcomes. World J Urol. 2013; 31: 431-434.
- Roach M, Hanks G, Thames H Jr, Schellhammer P, Shipley WU, Sokol GH, et al. Defining Biochemical failure following radiotherapy with or without hormonal therapy in men with clinically localized prostate cancer: Recommendations of the RTOG-ASTRO Phoenix Consensus Conference. Int J Radiat Oncol Biol Phys. 2006; 65: 965-974.
- Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6,336 patients and results of a survey. Ann Surg. 2004; 240: 205-213.
- Carson CC, Zincke H. Utz DC, Cupps RE, Farrow GM. Radical prostatectomy after radiotherapy for prostatic cancer. J Urol. 1980; 124: 237-239.
- Bates AS, Samavedi S, Kumar A, Mouraviev V,Rocco B, Coelho R, et al. Salvage robot assisted radical prostatectomy: A propensity matched study of perioperative, oncological and functional outcomes. Eur J Surg Oncol. 2015; 41:1540-1546.
- Heidenreich A, Richter S, Thuer D, Pfister D. Prognostic parameters, complications, and oncologic and functional outcome of salvage radical prostatectomy for locally recurrent prostate cancer after 21st-century radiotherapy. Eur Urol. 2010; 57: 437–443.
- Vallancien G, Gupta R, Cathelineau X, Baumert H, Rozet F. Initial results of salvage laparoscopic radical prostatectomy after radiation failure. J Urol. 2003; 170: 1838–1840.
- Ahallal Y, Shariat SF, Chade DC, Mazzola C, Reuter VE, Sandhu JS, et al. Pilot study of salvage laparoscopic prostatectomy for the treatment of recurrent prostate cancer. BJU Int. 2011; 108: 724–728.
- Jamal K, Challacombe B, Elhage O, Popert R, Kirby R. Dasgupta P, et al. Successful salvage robotic-asisted radical prostatectomy after external beam radiotherapy failure. Urology. 2008; 72: 1356-1358.
- Kaouk JH, Hafron J, Goel R, Haber GP, Jones JS. Robotic salvage retropubic prostatectomy after radiation/brachytherapy: initial results. BJU Int. 2008; 102: 93-96.
- Boris RS, Bhandari A, Krane LS, Eun D, Kaul S, Peabody JO. Salvage robotic-assisted radical prostatectomy: initial results and early report of outcomes. BJU Int. 2009; 103: 952-956.
- Eandi JA, Link BA, Nelson RA, Josephson DY, Lau C, Kawachi MH, et al. Robotic assisted laparoscopic salvage prostatectomy for radiation resistan prostate cancer. J Urol. 2010; 183: 133-137.
- Strope SA, Coelho M, Wood DP, Hollenbeck BK. Robot assisted salvage prostatectomy: evaluation of initial patient reported outcomes. J Endourol. 2010; 24: 425-427.
- Chauhan S, Patel MB, Coelho R, Liss M, Rocco B, Sivaraman AK, et al. Preliminary analysis of the feasibility and safety of salvage robotassisted radical prostatectomy after radiation failure: multi-institutional perioperative and short-term functional outcomes. J Endourol. 2011; 25: 1013-1019.
- Fine SW, Epstein JI. A contemporary study correlating prostate needle biopsy and radical prostatectomy Gleason score. J Urol. 2008; 179: 1335-1339.
- Fitzgerald TJ, Wang T, Goel HL, Huang J, Stein G, Lian J, et al. Prostate carcinoma and radiation therapy: therapeutic treatment resistance and strategies for targeted therapeutic intervention. Expert Rev. Anticancer Ther. 2008; 8: 967-974.
- Thompson IM, Valicenti RK, Albertsen P, Davis BJ, Goldenberg SL, Hahn C, et al. Adjuvant and salvage radiotherapy after prostatectomy: Guideline. J. Urol. 2013; 190 2: 441-449.
- National Comprehensive Cancer Network (NCCN) Clinical Practice Guideline in Oncology. Prostate Cancer.Version 1; 2015.
- Parekh A, Graham PL, Nguyen PL. Cancer control and complications of salvage local therapy after failure of radiotherapy for prostate cancer: a systematic review. Semin Radiat Oncol. 2013; 23: 222-234.