Debulking surgery in the setting of very high‐risk prostate cancer scenarios

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Abstract
Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Nowadays radical prostatectomy (RP) is considered an effective treatment in high‐risk prostate cancer (PCa) and the indications for a surgical approach are expanding, even in cases of very high PSA or node‐positive disease. We explored the outcomes of debulking surgery in the setting of these very high‐risk PCa patients, in order to assess its feasibility. This review confirms the important role achieved by surgery in the complex setting of patients with very high‐risk PCA. Excellent survival rates have been reported, even when PSA exceeds 100 ng/mL. The completion of RP with lymphadenectomy might give a survival benefit in patients who were found intraoperatively to be node‐positive. Furthermore, salvage RP confirmed to be the most effective treatment option after RT failure. On the contrary, up‐to‐date surgery of isolated nodal recurrences has shown only little benefit. Finally, there is no evidence supporting the efficacy of debulking surgery in metastatic or in hormone‐refractory tumours. An accurate selection of the patient is essential. OBJECTIVE: To conduct a critical analysis of the available literature on the feasibility of debulking surgery in the setting of very high‐risk prostate cancer (PCa) scenarios. PATIENTS AND METHODS: We performed a systematic literature search of PubMed and Embase using combinations of the following keywords: radical prostatectomy, surgery, high‐risk, high PSA (prostate‐specific antigen), radiorecurrent, hormone‐refractory, metastatic prostate cancer, salvage. With the term ‘very high‐risk PCa’ we indicated a clinical disease beyond the common definition of high‐risk PCa, i.e. any clinical stage > T3, N0 or N+, any PSA level > 50 ng/mL and any recurrent disease after primary treatment. RESULTS: Radical prostatectomy (RP) achieved excellent survival rates in high‐risk PCa, even in patients with very high PSA level. The completion of RP with lymphadenectomy might give a survival benefit in patients who were found intraoperatively to be node‐positive. Salvage RP was confirmed to be the most effective treatment option after radiotherapy failure, with increased functional outcomes and decreased side‐effects in the most recent series. Surgery of isolated nodal recurrences after previous radical therapy has shown little benefit according to the few available series. There is no evidence supporting the efficacy of debulking surgery in metastatic or hormone‐refractory PCa. CONCLUSION: Debulking surgery achieved an important role in several aggressive PCa scenarios. An accurate selection of the patient is essential.

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