title: Perineal salvage prostatectomy for radiation resistant prostate cancer.
abstract: OBJECTIVE
  No data are available on the use of perineal prostatectomy for salvage treatment of local recurrent prostate cancer after radiotherapy. Here we report on the clinical aspects and follow-up of salvage perineal prostatectomy.
  
  
  METHODS
  Twenty-seven patients underwent a perineal salvage prostatectomy from 1997-2005 for biopsy-proven local recurrent prostate cancer after external beam (n=22) or brachyradiotherapy (n=5). Staging included physical examination, prostate-specific antigen (PSA), transrectal ultrasound, computed tomography scan, and bone scan.
  
  
  RESULTS
  Mean PSA before surgery was 8.6 ng/ml (+/-2.8 ng/ml). Comparing clinical staging with final pathologic staging after salvage perineal prostatectomy showed a 67% clinical understaging. Mean blood loss was 677 cc, and perioperative morbidity consisted of prolonged anastomotic leakage (n=8), urosepsis (n=3), prolonged hematuria (n=3), urinary retention (n=2), and rectal perforation (n=1). One patient died during the postoperative course because of urosepsis and endocarditis. At an interval of at least 12 mo after surgery, 37% (10 of 27) and 7% (2 of 27) of patients reported normal continence and erectile function, respectively. Five patients died during a mean follow-up of 43 mo; two patients died of prostate cancer. Five-year biochemical recurrence-free survival was 31% (95%CI, 25-42%). In a multivariate Cox regression analysis the serum PSA and PSA doubling time (PSADT) at the time of surgery were the best predictors of biochemical recurrence-free survival. No patient with a PSA>2 ng/ml and a PSADT<12 mo was without biochemical recurrence 2 yr after surgery.
  
  
  CONCLUSIONS
  Salvage perineal prostatectomy showed functional results that favorably compare with the retropubic approach, but considerable morbidity is still frequent. Proper patient selection therefore is mandatory. A serum PSA level of >2 ng/ml and PSADT<12 mo independently predict shorter biochemical recurrence-free survival.
authors.affiliation: Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands. h.vd.poel@nki.nl
authors.forename: Henk G
authors.initials: HG
authors.lastname: van der Poel
authors.forename: Daan B
authors.initials: DB
authors.lastname: Beetsma
authors.forename: Hester
authors.initials: H
authors.lastname: van Boven
authors.forename: Simon
authors.initials: S
authors.lastname: Horenblas
mesh_terms: D000368:Aged; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D009367:Neoplasm Staging; D010502:Perineum / Q000601:surgery*; D011183:Postoperative Complications; D016016:Proportional Hazards Models; D017430:Prostate-Specific Antigen / Q000097:blood; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000473:pathology / Q000532:radiotherapy / Q000601:surgery*; D016879:Salvage Therapy; D016019:Survival Analysis; D016896:Treatment Outcome
chemical_list: D017430:Prostate-Specific Antigen