title: The role of palliative surgery in castration-resistant prostate cancer.
abstract: OBJECTIVE
  Androgen deprivation therapy with luteinising hormone releasing hormone (LHRH) analogues or antagonists represents the treatment of choice in men metastatic prostate cancer (PCA). Depending on the serum concentration of the prostate-specific antigen (PSA) nadir, the survival might vary between 11 and 78 months. About one-third of all patients without local treatment of the primary will develop significant complications of the lower and upper urinary tract because of local progression of PCA. It is the purpose of the review to inform the treating physician about palliative surgical options in men with castration-resistant prostate cancer (CRPC).
  
  
  RESULTS
  In men with CRPC and lower urinary tract symptoms, palliative transurethral resection of the prostate (TUR-P) can be performed with a 60-70% success rate. Infiltration of the pelvic floor, the bladder neck and trigone and the external urethral sphincter can make palliative radical surgery necessary. Bladder neck closure with continent vesicostomy, radical cystoprostatectomy with an incontinent urinary diversion, and anterior and posterior exenteration are individual therapeutic options in men with a good performance status and a considerable life expectancy. Symptomatic involvement of the upper urinary tract can be managed by placement of endoluminal stents or a percutaneous nephrostomy in men with a poor performance. In men with a good response to androgen deprivation therapy (ADT) and a good performance status reconstructive ureteral surgery might be considered and the options of ureteral reimplantation, ureter ileal replacement and a subcutaneous pyelovesical bypass have to be discussed.
  
  
  CONCLUSIONS
  There are various palliative surgical treatment options in the management of men with CRPC and symptomatic deterioration of the lower or the upper urinary tract, which should be considered in well selected patients. The indication to perform one of the above-mentioned surgical approaches needs to be discussed in a multidisciplinary tumour board.
authors.affiliation: Department of Urology, RWTH Uniklinik Aachen, Aachen, Germany.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Piper
authors.forename: Daniel
authors.initials: D
authors.lastname: Porres
authors.forename: David
authors.initials: D
authors.lastname: Pfister
authors.forename: Axel
authors.initials: A
authors.lastname: Heidenreich
mesh_terms: D006801:Humans; D008297:Male; D010166:Palliative Care / Q000379:methods*; D011468:Prostatectomy / Q000379:methods; D064129:Prostatic Neoplasms, Castration-Resistant / Q000601:surgery*; D013520:Urologic Surgical Procedures / Q000379:methods