Removal of the prostate following first-line radiotherapy

Percutaneous radiotherapy and brachytherapy are standard treatments for prostate carcinoma. Depending on the stage of the tumour when it is first detected, up to 50% of patients may experience a recurrence within five years of radiotherapy.

What constitutes tumour recurrence after radiotherapy?

Recurrence is defined as a significant increase in a patient’s PSA level following radiotherapy. The American Society for Therapeutic Radiology and Oncology (ASTRO) issued the ‘Phoenix criteria’, which defines PSA recurrence as a rise of at least 2 ng/ml in a patient’s PSA level above their lowest post-radiotherapy PSA level (nadir).

When might a salvage operation be beneficial?

If local recurrence is diagnosed at an early stage, a radical prostatectomy can be beneficial in some cases. Unfortunately, PSA progression following radiotherapy does not indicate whether the cause is purely local recurrence in the prostate or if the cancer has metastasised, in which case local treatment would no longer be medically sensible. For this reason, if surgery is a possibility in principle, further staging tests must be carried out to demonstrate local recurrence and rule out metastases as far as possible. Estimates suggest that only 20% of patients who experience a biochemical recurrence (PSA increase) after radiotherapy actually experience local recurrence of prostate cancer.

Accompanies you through this topic

Prof. Dr. Hans Heinzer
Faculty member

What are the chances of a cure following salvage surgery?

Although it has the potential to cure prostate cancer, patients are only offered the possibility of a salvage operation following very careful consideration and selection. A salvage procedure must be clearly indicated for the specific patient. Very few studies to date have examined the chances of recovery following a salvage operation with a large number of patients. No randomised studies have been conducted to compare a salvage procedure with alternative treatments, such as hormone therapy. Our experience to date shows that 47–82% of patients remain PSA-negative for five years after salvage surgery. Oncological literature describes numerous factors correlated with better treatment outcomes from surgery. These include a lower PSA (< 10 ng/ml) and a Gleason score ≤ 7 in biopsies prior to first-line radiotherapy. A Gleason score ≤ 7 in the biopsy and a slow increase in the patient’s PSA level after radiotherapy are also among the favourable prognostic factors.

What are the risks involved in salvage surgery?

Salvage surgery involves a higher degree of difficulty because the radiotherapy may have significantly altered the tissue. Guidelines therefore recommend that only experienced surgeons perform the procedure. At the Martini-Klinik, our doctors have routinely performed this type of radical prostatectomy for many years.

Although the complication rate in salvage surgery is higher than for primary surgery, most patients can undergo the surgery with acceptable functional results. As it is often not possible to spare the nerves during surgery, patients must contend with the strong possibility of erectile dysfunction. However, many patients will have already experienced considerably reduced erectile function as a side effect of radiotherapy. In addition, a higher proportion of patients experience persistent post-operative urinary incontinence, though this is usually only low-grade incontinence. Due to increased tissue scarring, anastomotic strictures and rectal injuries are more common.

What surgical technique is used?

In most cases, the special circumstances following radiotherapy means that an open radical prostatectomy is carried out. In principle, however, a minimally invasive, robotic-assisted surgery may also be an option. The surgeon makes a decision regarding surgical technique in a detailed consultation with the patient.

What tests have to be carried out before salvage surgery?

In the first instance, a prostate biopsy must be carried out to confirm local recurrence of prostate cancer. Experience shows that a prostate biopsy can also be carried out following radiotherapy without an elevated risk. A bone scan (bone scintigraphy) and CT/MRI are usually also carried out to rule out metastases. However, this test cannot fully exclude the risk of micrometastasis. In principle, a clinical examination should be carried out in addition to imaging procedures to document the operable findings.

Can salvage surgery be carried out after a first-line treatment other than radiotherapy?

In principle, salvage surgery can be performed after other first-line treatments for prostate carcinoma, such as HIFU, cryotherapy, laser therapy or thermotherapy. The criteria are broadly similar to the criteria following first-line radiotherapy. However, as less experience has been gained of such cases and less data collected, patients must make a personal decision about whether to undergo salvage surgery.

Summary

Salvage radical prostatectomy is a potential treatment option for local recurrence following first-line radiotherapy. It is vital to weigh up the potential risks and benefits of the surgery for each individual patient. This involves an in-depth consultation with the urologist to determine whether the relevant criteria for surgery have been met. Due to the pre-existing damage to the tissue caused by the radiotherapy, salvage surgery entails a somewhat higher risk of complications than when radical prostatectomy is used as a first-line treatment. In experienced centres like the Martini-Klinik, however, the complication rate is only slightly increased. In principle, and depending on the specific indications, salvage surgery can be carried out after other prostate carcinoma treatments such as HIFU, cryotherapy, laser therapy or thermotherapy. Here at the Martini-Klinik, our doctors would be happy to hold a detailed consultation with you.

Can I undergo prostate surgery even after radiotherapy?

Estimates suggest that only 20% of patients who experience a biochemical recurrence (PSA increase) after radiotherapy actually experience local recurrence of prostate cancer. For this reason, if surgery is a possibility in principle, further staging tests must be carried out to demonstrate local recurrence and rule out metastases as far as possible. Salvage surgery involves a higher degree of difficulty because the radiotherapy may have significantly altered the tissue. Guidelines therefore recommend that only experienced surgeons perform the procedure.