Evaluation of the safety and efficacy of surgery for radio-recurrent prostate cancer: a systematic review and meta-analysis

TL;DR

This study evaluates the effectiveness and safety of surgery for prostate cancer that returns after radiation therapy, finding that robot-assisted surgery and certain patient factors improve outcomes.

Contribution

The study provides a meta-analysis of recurrence-free survival and complications in salvage surgery for radio-recurrent prostate cancer.

Findings

Median recurrence-free survival after salvage surgery was 63.9 months with 51.2% at 5 years.

Robot-assisted surgery and adjuvant androgen deprivation therapy were associated with better survival outcomes.

Severe complications occurred in 15.9% of patients, highlighting the risks of salvage surgery.

Abstract

Surgery plays a critical role in managing radio-recurrent prostate cancer (PCa). This study aims to comprehensively review its effectiveness and associated severe complications.

A thorough review of PubMed and EMBASE databases up to July 2024 was conducted, focusing on recurrence-free survival (RFS) with salvage surgery across various subgroups. Severe complications were also assessed using the Clavien-Dindo Scale (CDS). Survival curves were reconstructed using WebPlotDigitizer and a newly developed shiny application.

Forty-four studies were included, with 17 papers (2056 patients) contributing to survival curve reconstruction. Among 1654 patients treated with salvage surgery after eliminating duplicate cases, the median RFS was 63.9 months, with 2-, 3-, and 5-year rates of 65.6%, 59.3%, and 51.2%, respectively. Factors associated with better RFS included robot-assisted surgery [hazard ratio (HR):1.49, p < 0.001], lower rates of seminal vesicle invasion (SVI) (HR: 0.75, p = 0.006) and lymph node involvement (LNI) (HR: 0.74, p = 0.006), higher proportion of adjuvant androgen deprivation therapy (ADT) (HR: 2.96, p < 0.001), and higher values of pathological Gleason scores (GS) (≤7/≥8) (HR:1.30, p < 0.001). Severe complications (grade ≥ IIIa) occurred in 404 out of 2537 patients (15.9%, 95% CI: 14.5 to 17.4).

This study comprehensively assesses complications and conducts a pooled analysis of RFS for salvage surgery in radio-recurrent PCa. Robot-assisted surgery, lower rates of SVI and LNI, adjuvant ADT, and higher proportions of pathological GS ≤7 appear promising as prognostic factors for RFS. However, confirming these findings will necessitate randomized controlled trials due to low levels of evidence and study heterogeneity.

Figures