Background: Effective salvage of locally recurrent prostate cancer after definitive radiation is typically disappointing and may be associated with significant complications. Methods: 133 consecutive prostate cancer patients (ages 46-78) with biopsy proven local failures were treated between 2001 and 2021 and followed, prospectively with respect to clinical and/or biochemical failure and toxicity. Pre-recurrence treatment had consisted of external beam radiation (Photons: 102 patients, Protons: 16 patients) or iodine 125 brachytherapy (15 patients). Prior to salvage treatment, an extensive workup ruled out gross extracapsular extension or distant disease spread. Salvage treatment consisted of an attenuated dose of IMRT to the prostate (1200 cGy/8 fxs) followed by an attenuated Pd-103 brachytherapy boost (median 9000 cGy) within 24-72 hours. The Pd-103 isotope was used given its steep radial dose fall off, thereby reducing dosage to previously irradiated surrounding tissues. All patients were treated with a median 6 months of androgen deprivation. Mean pretreatment PSA was 5.9 ng/mL (range 1.9 - 22.3, median 3.9) with 64 patients having a Gleason score of greater than or equal to 8, 61 patients having a Gleason score of 7, and 8 patients having a Gleason score of 6. Follow-up from date of implant ranged from 3 years to 20 years (median 14 years). Biochemical failure was defined using PSA greater than or equal to 0.2 and nadir +2 at last follow up. All biochemically failing patients underwent transperineal prostate biopsies (median 18 cores). Results: Overall, 72% (96/133 patients) have maintained a PSA less than or equal to 0.2 ng/mL at median 14 years. Biochemical freedom at 5 years was 91%. PSA prior to re-treatment was highly predictive of distant progression with no patient having a PSA greater than 15 being successfully salvaged. Prostate biopsies of failing patients revealed only 3 local failures. 4 patients required post-implant TURP and 2 TURP patients developed low volume stress incontinence, 2 patients developed urethral strictures which were successfully treated to resolution. No patient has developed rectal ulceration, prostatic-vesicorectal fistula, or chronic cystoproctitis. Conclusions: This study helps strengthen the rationale for the use of Brachytherapy-based regimens in the treatment of radiorecurrent prostate cancer. In view of its even steeper radial dose falloff, we are currently exploring the advantages of Cs-131 in these patients.