The significance of palliative surgery in castration-resistant prostate cancer

Abstract

If prostate cancer recurs after primary treatment, deprivation therapy with LHRH analogues or antagonists is the treatment of choice in men with metastatic prostate cancer. However, this treatment only achieves palliative results. Median time to progression ranges between 11 and 78 months. After the introduction of Docetaxel as a first-line treatment in castration-resistant prostate cancer (CRPCA) and cabazitaxel as a second-line chemotherapy, several new drugs containing abiraterone, enzalutamide, radium 223 and sipuleucel-T have become available, which can lead to complete or partial remissions in metastasis, but do not have an effect on the prostate itself as has been shown recently. As a result of local progression of CRPCA, local complications of the urinary tract such as subvesical obstruction, recurrent gross haematuria with or without clotting, upper urinary tract dilatation, rectourethral or rectovesical fistulae and rectal obstruction will occur in about one third of all patients. Several surgical treatment options are available to manage the aforementioned complications. In patients with local progressive CRPCA and lower urinary tract symptoms, palliative TUR-P, radical prostatectomy or radical cystoprostatectomy with urinary diversion and even anterior and posterior exenteration can be performed in selected patients, requiring a preoperative multiparametric MRI of the prostate and the pelvic floor along with a laboratory examination to optimise surgical techniques and perioperative outcomes. In case of symptomatic involvement of the upper urinary tract system, the placement of endoluminal DJ stents or percutaneous nephrostomy in men with a poor performance status and a short life expectancy is the treatment of choice. In men with an ECOG performance status of 0 to 1, reconstructive surgery such as ureteral reimplantation, ileal ureteral replacement or placement of a subcutaneous pyelovesical bypass is an appropriate treatment option. To summarise, the aforementioned palliative surgical treatment options should be provided for selected patients and performed by well-experienced urologists.