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

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.