The Role of Palliative Surgery in Castration-Resistant Prostate Cancer

Abstract

Androgen deprivation therapy (ADT) with luteinizing hormone-releasing hormone (LHRH) analogues or antagonists represents the treatment of choice in men with 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. In castration-resistant PCA (CRPC), all new medical treatment options can induce complete and partial remissions in metastatic foci, but they have no profound effect on the prostate itself, as has been shown recently. About one-third of all patients without local treatment of the primary will develop significant complications of the lower and upper urinary tract due to local progression of the PCA. In men with CRPC and lower urinary tract symptoms, palliative transurethral resection of the prostate (TURP) 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 the placement of endoluminal stents or a percutaneous nephrostomy in men with poor performance. In men with a good response to 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. The indication to perform one of the above-mentioned surgical approaches needs to be discussed in a multidisciplinary tumor board.

Pelvic exenteration surgery in patients with locally advanced castration‐naïve and castration‐resistant, symptomatic prostate cancer

“…Infiltration of those organs might result in symptoms such as bleeding, urinary retention, perineal pain and hydronephrosis. However, most patients are managed conservatively by palliative TURP, transurethral or suprapubic catheters, or endoluminal or percutaneous urinary diversion, which all have a negative impact on quality of life [1]. Even in the current era, locoregional symptoms are observed in many men with newly diagnosed de novo metastatic prostate cancer, exerting a negative impact on survival [2].…”

Clinical course of metastatic prostate cancer

“…Indien de klachten berusten op een blaasontledigingsstoornis dient deze stoornis primair medicamenteus behandeld te worden (alfablokkers). Bij onvoldoende resultaat is een palliatieve TURP een goed alternatief met succespercentages tot 90% en acceptabele complicaties die vergelijkbaar zijn met die van een TURP voor BPH [43]. Indien ook die behandeling onvoldoende effect heeft of indien een patiënt niet meer geopereerd kan of wil worden rest, zeker bij forse residuvorming of retentie, CIC, of een permanente transurethrale of suprapubische katheter.…”

Rekonstruktive Chirurgie des Ureters

“…Das Detour-System stellt jedoch eine sehr gute Alternative in der palliativen uro-onkologischen Chirurgie mit Aufrechterhaltung der Lebensqualität dar und sollte häufiger in das therapeutische Armentarium eingefügt werden [35].…”