[Local recurrence after radical prostatectomy for prostatic cancer]

The local recurrence rate after radical prostatectomy for prostate cancer has varied across studies but seems sufficiently high (20 to 40%) to warrant a reappraisal of the oncological usefulness of this procedure performed in isolation using current techniques. Local recurrence can be either biological or clinical. In biological recurrences, the only abnormality is recurrent PSA elevation. It has been suggested that this event, even in the absence of ultrasound changes or histological documentation, should lead to additional therapy, usually in the form of local radiation therapy, and that the efficacy criterion for this treatment should be a fall in PSA to undetectable levels. However, differences in the "ultrasensitive" assays used to detect PSA pose a serious obstacle to comparisons of published studies. Furthermore, in most publications, the pathological stage is more severe than the clinical stage, and this clinical underestimation of disease severity complicates the evaluation of recurrence rates. In clinical recurrences, rectal digital examination or endorectal ultrasonography show abnormalities and, more importantly, examination of a biopsy specimen establishes that these abnormalities are due to malignant disease. Symptoms may or may not be present. Many authors, particularly in Europe, feel that only clinical recurrences warrant additional treatment, usually in the form of radiation therapy. However, as a preliminary, all available imaging techniques should be used to confirm that the absence of metastases. A valuable tool in this situation is the study of PSA kinetics (elevation rate or postoperative doubling time). If the recurrence seems local, radiation therapy alone is the best initial option, since concomitant hormone therapy leads to a decrease in PSA levels even in the presence of metastatic disease, thus depriving the patient and physician of a valuable therapeutic test. Success rates after radiation therapy for recurrences have varied widely across studies. Some authors consider that this treatment approach is ineffective or provides only transient benefits. Follow-ups were often short, particularly given the considerable variability of the natural history of prostate cancer. The enthusiasm initially generated by radical prostatectomy should be tempered, at least regarding the possibility of a complete cure.