For patients with a rising PSA after radiation therapy, salvage prostatectomy can be considered if the disease was "curable" at the outset, if persistent disease has been documented by a biopsy of the prostate, and if no metastatic disease is seen on imaging studies. Unfortunately, case selection is poorly defined in most series, and morbidities are significant. As currently performed, virtually all patients are impotent after salvage radical prostatectomy, and ~45% have either total urinary incontinence or stress incontinence. Major bleeding, bladder neck contractures, and rectal injury are not uncommon. In many cases, the rise in PSA after surgery or. | Chapter 091. Benign and Malignant Diseases of the Prostate Part 8 For patients with a rising PSA after radiation therapy salvage prostatectomy can be considered if the disease was curable at the outset if persistent disease has been documented by a biopsy of the prostate and if no metastatic disease is seen on imaging studies. Unfortunately case selection is poorly defined in most series and morbidities are significant. As currently performed virtually all patients are impotent after salvage radical prostatectomy and 45 have either total urinary incontinence or stress incontinence. Major bleeding bladder neck contractures and rectal injury are not uncommon. In many cases the rise in PSA after surgery or radiation therapy indicates subclinical metastatic disease. In these cases the need for treatment depends in part on the estimated probability that the patient will show evidence of metastatic disease on a scan and in what time frame. That immediate therapy is not always required was shown in a series where patients received no systemic therapy until metastatic disease was documented. Overall the median time to metastatic progression was 8 years and 63 of the patients with rising PSA values remained free of metastases at 5 years. Factors associated with progression included the Gleason grade of the primary tumor time to recurrence and PSA doubling times. For those with Gleason grade 8 tumors the probability of metastatic progression was 37 51 and 71 at 3 5 and 7 years respectively. If the time to recurrence was 2 years and PSA doubling time was long 10 months the proportion with metastatic disease at the same time intervals was 23 32 and 53 vs. 47 69 and 79 if the doubling time was short 10 months . A difficulty with predicting the course of disease in the rising PSA state is that most patients receive some form of therapy before the development of metastases. Nevertheless predictive models continue to be refined. PSA doubling times are prognostic for survival. In .
