Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA.
Eur Urol. 2012 May;61(5):961-71. doi: 10.1016/j.eururo.2012.01.022. Epub 2012 Jan 23.
Prostate cancer (PCa) recurrence following definitive radiation therapy (RT) remains a vexing challenge for the practicing physician. Salvage radical prostatectomy (SRP) has not been recognized yet as a valuable therapeutic option.
We critically analyzed the currently available evidence on SRP as to patient selection, predictive oncologic factors, surgical technique, cancer control, surgical complications, functional outcomes, and comparison to other salvage therapies.
A systematic review of the literature was performed in June 2011 using the Medline, Embase, and Web of Science databases, limiting the review to English-language articles published between January 1980 and June 2011. All authors reviewed the list of references and added papers relevant to the topic of the review prior to the analysis. The panel selected 40 articles according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria.
Positive surgical margins in SRP varied from 43% to 70% in earlier publications versus 0-36% in recent publications, and pathologic organ-confined disease (OCD) was found in 22-53% versus 44-73% in earlier versus recent publications. Biochemical recurrence-free probability after SRP ranged from 47% to 82% at 5 yr and from 28% to 53% at 10 yr. Cancer-specific survival (CSS) and overall survival varied from 70% to 83% and 54% to 89% at 10 yr. Pre-SRP prostate-specific antigen value and prostate biopsy Gleason score were the strongest prognostic risk factors for progression-free survival, OCD, and CSS. Open, laparoscopic, and robotic techniques were shown to be feasible in the hands of experienced surgeons. The most frequent complications included anastomotic stricture (7-41%) followed by rectal injury (0-28%). Major complications (modified Clavien classification grade 3-5) varied from 0% to 25%. Most complications were less frequent in more recent series, except for anastomotic stricture. The majority of patients had erectile dysfunction prior to SRP (50-91%) and 80-100% after SRP. Urinary continence ranged from 21% to 90% after surgery. Limitations of this review include the absence of prospective studies and lack of comparative analyses between SRP and other therapies.
In selected patients with confirmed, localized, radiation-recurrent PCa, SRP may effectively promote durable cancer control with acceptable associated surgical morbidity and variable functional recovery.
根治性放疗（RT）后前列腺癌（PCa）的复发仍然是临床医生面临的一个难题。挽救性前列腺切除术（SRP）尚未被认为是一种有价值的治疗选择。
我们对 SRP 的现有证据进行了批判性分析，包括患者选择、预测性肿瘤因素、手术技术、癌症控制、手术并发症、功能结果以及与其他挽救性治疗的比较。
2011 年 6 月，使用 Medline、Embase 和 Web of Science 数据库进行了系统评价，将综述限于 1980 年 1 月至 2011 年 6 月期间发表的英文文章。所有作者均回顾了参考文献列表，并在分析前添加了与综述主题相关的论文。该小组根据系统评价和荟萃分析的首选报告项目（PRISMA）标准选择了 40 篇文章。
在早期出版物中，SRP 的阳性手术切缘率为 43%-70%，而在最近的出版物中为 0%-36%，在早期出版物中发现的病理性器官局限性疾病（OCD）为 22%-53%，而在最近的出版物中为 44%-73%。SRP 后 5 年和 10 年的生化无复发生存率分别为 47%-82%和 28%-53%。10 年时癌症特异性生存率（CSS）和总生存率分别为 70%-83%和 54%-89%。术前前列腺特异性抗原值和前列腺活检 Gleason 评分是无进展生存率、OCD 和 CSS 的最强预后危险因素。开放式、腹腔镜式和机器人技术在经验丰富的外科医生手中被证明是可行的。最常见的并发症包括吻合口狭窄（7%-41%）和直肠损伤（0%-28%）。主要并发症（改良 Clavien 分级 3-5）在 0%-25%之间变化。除吻合口狭窄外，最近的系列中大多数并发症的发生率较低。大多数患者在 SRP 前有勃起功能障碍（50%-91%），在 SRP 后有 80%-100%。手术后尿控率为 21%-90%。本综述的局限性包括缺乏前瞻性研究以及缺乏 SRP 与其他治疗方法的比较分析。
在确诊为局限性、放射性复发的 PCa 的选定患者中，SRP 可能通过可接受的相关手术发病率和可变的功能恢复有效地促进持久的癌症控制。
