Salvage radical prostatectomy – An option after radiation

Salvage radical prostatectomy after radiation therapy has failed has really only gained favor in recent years.

This is because it has been associated with a high occurrence of side effects such as:

  • Impotence
  • Incontinence
  • Risk of death

Challenging procedure

Salvage radical prostatectomy is definitely a more challenging procedure, especially for younger men or men who have a life expectancy of greater than 10 years.

The good news is that two large scale studies have demonstrated 10-year survival rates of 65% to 73% with this procedure.

It is definitely not a surgery that an average surgeon can perform. It requires the utmost skill and training.

If you are considering this option, it is imperative that you find a surgeon who not only has extensive experience in this technique, but also has a solid history of successful outcomes.

Generally, this is a treatment option when doctors believe the cancer is still localized, which means it has not spread beyond the prostate gland.

Why so difficult?

The challenge with salvage surgery is that the tissues that surround the prostate gland have undergone substantial damage from radiation.

This makes it harder for the surgeon to see and cut out all of the areas that need to be removed.

It may also prevent the surgeon from being able to perform a nerve-sparing procedure.

Rate of side effects

While it has been reported that the complication rates are similar to that of traditional radical prostatectomy, the rate of long-lasting or permanent incontinence is reported to be between 50% and 96%, depending on the type of previous radiation therapy.

  • In one study of 41 men, the rates of incontinence and impotence were reported to be moderately higher a year after this prostate cancer surgery was performed, as compared to first-line (first-time) surgery
  • An estimated 20% of men will require a cystoprostatectomy in order for the surgeon to remove all the cancer, which involves removal of the prostate gland and the bladder

General medical consensus

Seabra et al concluded from their study of 42 men who underwent salvage radical prostatectomy that it should only be offered to men who are more concerned about survival rather than quality of life.

After reviewing clinical studies from 1980 to 2012, Rosoff et al concluded that the ideal candidate is a man who has a:

  • Life expectancy of greater than 10 years
  • PSA less than 10 ng/ml and had an initial clinical staging of T1 or T2 prostate cancer

A prostate biopsy and imaging studies should be performed to rule out metastatic prostate cancer (cancer that has spread beyond the prostate gland) prior to salvage radical prostatectomy.

Clinical results

  • Biochemical recurrence-free probability at 5 years ranged from 37 to 55%
  • The estimated cancer-specific survival at 10 years ranged from 70 to 83%

As with any prostate cancer treatment, make sure that you and your loved one thoroughly discuss all of the pros and cons of treatment with his doctor before you make a decision.

Back to if cancer returns
Salvage radiation
Salvage cryotherapy
Hormone treatment
Watchful waiting (or active surveillance)

Bianco FJ, Scardino PT, Stephenson AJ, Diblasio CJ, Fearn PA, Eastham JA. Long-term oncologic results of salvage radical prostatectomy for locally recurrent prostate cancer after radiotherapy.Int J Radiat Oncol Biol Phys.;62(2):448-53.
Heidenreich A, Thüer D, Pfister D. Salvage radical prostatectomy. Panminerva Med. 2010 Sep;52(3):231-8.
Moul JW, Banez LL, Freedland SJ. Rising PSA in nonmetastatic prostate cancer. Oncology.2007;21(12):1436-1454.
Rosoff JS, Savage SJ, Prasad SM.  Salvage radical prostatectomy as management of locally recurrent prostate cancer: outcomes and complications. World J Urol.  2013 Jan 29. [Epub ahead of print]
Seabra D, Faria E, Dauster B, Rodrigues G, Fava G. Critical analysis of salvage radical prostatectomy in the management of radioresistant prostate cancer. Int Braz J Urol.2009;35(1):43-8.
Ward JF, Pagliaro LC, Pisters LL. Salvage therapy for radiorecurrent prostate cancer. Curr Probl Cancer. 2008;32(6):242-71.

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