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.
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.