Radical salvage prostatectomy. Treatment of local recurrence of prostate cancer after radiotherapy

External beam radiation and low-and high-dose interstitial brachytherapy represent therapeutic alternatives to radical prostatectomy for organ-confined and locally advanced prostate cancer. Local recurrences are described in 5-35% of the patients depending on the individual risk profile, and most recurrences are detected due to asymptomatic PSA rise only. According to the most recent data, recurrences are defined by a PSA increase >2 ng/ml above the post-radiation nadir. Radical salvage prostatectomy represents a secondary local treatment with curative intent in patients with organ-confined recurrences. Preoperative risk factors predicting organ-confined disease are initial LDR brachytherapy, preoperative Gleason biopsy score <= 6, <= 50% biopsy cores involved with cancer, and a PSA doubling time >12 months. Metastatic disease should be ruled out preoperatively by skeletal scintigraphy, computed tomography, or magnetic resonance imaging of the abdomen and the small pelvis, and/or choline PET/CT. Functionality of the lower urinary tract is evaluated by urethrocystoscopy and urodynamics. The most appropriate candidates for radical salvage prostatectomy are patients with organ-confined disease or those with symptomatic local recurrences. In experienced hands, morbidity is low with a continence rate of 83-96% depending on the type of previous radiation therapy. Long-term oncological control can be achieved in more than 80% of the patients.