CONTEXT Despite excellent cancer control with the treatment of localized prostate cancer (PCa), some men will experience a recurrence of disease. The optimal management of recurrent disease remains uncertain. OBJECTIVE To systematically review recent literature regarding management of biochemical recurrence after primary treatment for localized PCa. EVIDENCE ACQUISITION A comprehensive systematic review of the literature was performed from 2000 to 2012 to identify articles pertaining to management after recurrent PCa. Search terms included prostate cancer recurrence, salvage therapy, radiorecurrent prostate cancer, post HIFU, post cryoablation, postradiation, and postprostatectomy salvage. Studies were selected according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines and required to provide a comprehensive description of primary and secondary treatments along with outcomes. EVIDENCE SYNTHESIS The data from 32 original publications were reviewed. The most common option for local salvage therapy after radical prostatectomy (RP) was radiation. Options for local salvage therapy after primary radiation included RP, brachytherapy, and cryotherapy. Different definitions of recurrence and risk profiles among patients make comparative assessment among salvage treatment modalities difficult. Triggers for intervention and factors predicting response to salvage therapy vary. CONCLUSIONS Radiation therapy (RT) after RP can provide durable prostate-specific antigen (PSA) responses in a sizeable percentage of men, especially when given early (ie, PSA <1 ng/ml). Though a few studies suggest improvements in mortality, prospective randomized trials are needed and underway. The role of salvage treatment after RT is less clear.